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THE  increasing  attention  given  of  late  years  to  personal 
and  public  hygiene  is  one  of  the  most  encouraging  signs 
of  social  improvement.  Books,  periodicals,  tracts,  and  lec- 
tures, have  disseminated  information  on  the  subject  of  great 
value ;  but  it  is  notorious  that  most  of  the  cheap  and  popu- 
lar kind  are  crude  compilations  of  incompetent  persons. 

Several  eminent  medical  and  scientific  men  of  London 
accordingly  combined  to  prepare  a  series  of  HEALTH  PRIM- 
ERS, of  a  character  to  entitle  them  to  the  fullest  public 
confidence.  They  are  to  be  brief,  simple,  elementary  in 
statement,  and  filled  with  substantial  information,  suitable 
for  the  guidance  of  grown-up  people.  Each  primer  is  to 
be  the  work  of  a  specially  competent  writer ;  while  the 
choice  of  topics  and  the  critical  supervision  will  be  in  the 
hands  of  an  able  and  responsible  committee.  The  series 
will  deal  with  the  chief  hygienic  subjects  of  vital  impor- 


tance,   and  will  form  a  cheap  and  compendious  popular 
library  of  health-manuals  for  every  household. 

As  these  little  books  are  produced  by  English  authors, 
they  are  naturally  based  very  much  upon  English  expe- 
rience, but  it  matters  little  whence  illustrations  upon  such 
subjects  are  drawn,  because  the  essential  conditions  of 
avoiding  disease  and  preserving  health  are  to  a  great  degree 
everywhere  the  same. 

Volumes  of  the  Series. 


EXERCISE     AND     TRAINING. 

'(Illustrated.) 


'1HE   HEART  AND  ITS    FUNG 
TIONS. 


ALCOHOL:  ITS  USE  AND  ABUSE.  I    THE  HEAD. 

THE    HOUSE    AND    ITS    SUR-  !    CLOTHING  AND  DRESS. 

ROUNDINGS.  WATER. 

PREMATURE  DEATH:  ITS  PRO-  THE  SKIN  AND  ITS  TROUBLES. 

MOTION  OR  PREVENTION.  FATIGUE  AND  PAIN. 

PERSONAL  APPEARANCES  IN  THE  EAR  AND  HEARING. 

HEALTH     AND      DISEASE.  THE  EYE  AND  VISION. 

(Illustrated.)  TEMPERATURE    IN    HEALTH 


BATHS  AND  BATHING. 


AND  DISEASE. 


In  square  i6mo  volumes,  cloth,  price,  40  cents  each. 

For  sale  by  all  booksellers.  Any  volume  mailed,  post- 
paid, to  any  address  in  the  United  States,  on  receipt  of  the 
price. 

D.  APPLE  TON  &  CO.,  Publishers, 

549  &  551  BROADWAY,  NEW  YORK. 


HEALTH  PRIMERS. 

No.  S. 


HEALTH     PRIMERS. 


E  D  I  T  O  R  S'. 

J.  LANGDON  DOWN,  M.D.,  F.R.C.P. 
HENRY  POWER,  M.  B.,  F.  R.  C.  S. 
J.  MORTIMER-GRANVILLE,  M.D. 
JOHN  TWEEDY,  F.  R.  C.  S. 


CONTRIBUTORS   TO   THE    SERIES. 

G.  W.  BALFOUR,  M.  D.  St.  And.,  F.  R.  C.  P.  Edin. 

J.  CRICHTON-BROWNE,  M.  D.  Edin.,  F.  R.  S.  Edin. 

SIDNEY  COUPLAND,  M.D.  Lend.,  M.R.C.P. 

JOHN  CURNOW,  M.  D.  Lond.,  F.  R.  C.  P. 

J.  LANGDON  DOWN,  M.D.  Lond.,  F.R.C.  P. 

TILBURY  FOX,  M.  D.  Lond.,  F.  R.  C.  P. 

J.  MORTIMER-GRANVILLE,  M.  D.  St.  And.,  F.  G.  S.,  F.  S.  S. 

W.  S.  GREENFIELD,  M.D.  Lond.,  M.R.C.  P. 

C.  W.  HEATON,  F.C.S.,  F.  I.  C. 

HARRY  LEACH,  M.R.C.P. 

G.  V.  POORE,  M.  D.  Lond.,  F.  R.  C.  P. 

HENRY  POWER,  M.  B.  Lond.,  F.  R.  C.  S. 

W.  L.  PURVES,  M.  D.  Edin.,  M.  R.  C.  S. 

J.  NET  TEN  RADCLIFFE,  Ex-Pres.  Epidl,  Soc.,  etc. 

C.  H.  RALFE,  M.  A.,  M.  D.  Cantab.,  F.  R.  C.  P. 

S.  RINGER,  M.D.  Lond.,  F.R.C.P. 

JOHN  TWEEDY,  F.  R.  C.  S. 

JOHN  WILLIAMS,  M.  D.  Lond.,  M.  R.  C.  P. 


HEALTH  PRIMERS. 


PERSONAL  APPEARANCES 


IN 


HEALTH  AND  DISEASE. 


BY 

SIDNEY   COUPLAND,   M.  D. 


rr 

•'9iu  v 


NEW  YORK: 

D.    APPLETON    AND    COMPANY, 

549  &  551   BROADWAY. 

1879. 


v 


BIOLOGY 

LIBRARY 

G 


CONTENTS. 


PAGK 

INTRODUCTION 5 

THE  FORM  AND  SIZE  OF  THE  HUMAN  BODY    ....  7 

CHANGES  IN  THE  FATTY  LAYER 24 

CHANGES  IN  THE  BONY  FRAMEWORK 36 

CHANGES  IN  ORGANS 45 

ARTIFICIAL  ALTERATIONS  IN  SHAPE 60 

THE  COLOUR  OF  THE  HUMAN  BODY 64 

CHANGES  IN  COLOUR  IN  HEALTH 80 

CHANGES  IN  COLOUR  IN  DISEASE 87 

ON  'TEMPERAMENT,'  *  HABIT,'  AND  'TONE'    .     .     .     .  92 


PERSONAL  APPEARANCES 

IN  HEALTH  AND  DISEASE. 


INTRODUCTION. 

IF  a  person  wholly  unacquainted  with  the  structure  of  the 
body  or  with  any  of  its  functions  could  be  confronted  with 
a.  number  of  individuals,  some  of  whom  are  what  we  call 
healthy  and  others  what  we  call  unhealthy,  he  would 
have  very  little  difficulty  in  discriminating  the  one  group 
from  the  other.  The  unhealthy  ones  might  none  of 
them  be  suffering  from  any  grave  disease,  they  might 
even  be  pursuing  their  ordinary  avocations,  and  yet 
without  putting  a  single  question  to  them  this  unskilled, 
and  possibly  not  very  discerning^  individual  would  have 
but  little  hesitation  in  making  the  broad  distinction.  He 
could  not  tell  why  he  arrived  at  that  conclusion,  he 
might  only  say  that  these  did  not "  look  so  well "  as  those ; 
yet  he  would  have  gone  through  the  process  of  picturing 
to  himself  what  a  healthy  man  should  be,  and  would 
contrast  his  ideal  with  the  forms  before  him.  It  is  very 
likely  indeed  that  here  and  there  lie  might  make  a 
mistake,  for  being  an  undiscerning  man  he  might  be 
deceived  by  the  appearance  of  health  which  some  dis- 


6        PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

eases  give,  or  by  not  knowing  the  limits  to  which  a  body 
performing  all  its  functions  well  enough  to  be  con- 
sidered healthy  may  exhibit  a  leanness  to  which  he 
would  feel  inclined  to  apply  the  term  of  illness.  Still, 
with  some  few  exceptions,  he  would  be  in  the  main  right. 
If  he  were  asked  to  push  his  conclusions  further,  and  to 
point  out  among  the  unhealthy  ones  those  whom  he 
deemed  most  and  those  least  ill,  and  try  and  construct 
a  scale  of  ill-health  from  the  frames  before  him,  it  is 
likely  that  he  would  go  very  wide  of  the  mark  indeed. 

Now  it  is  the  object  of  this  little  book  to  try  and  explain 
as  briefly  as  possible  how  and  why  variations  that  are  so 
plain  on  the  surface  can  be  taken  as  indices  of  disorder 
within,  to  give  the  reasons  for  form-changes  which  occur 
within  the  limits  of  health,  and  for  those  which  mark  the 
departure  from  those  boundaries.  It  cannot  be  denied 
that  this  is  a  subject  of  very  great  importance;  but 
it  is  beset  with  difficulties  on  all  sides,  difficulties  such 
as  those  which  the  mere  definitions  of  the  terms  "  health'* 
and  "  non-health  "  imply. 

One  great  difficulty  stares  us  in  the  face  at  the  outset, 
and  it  is  this  :  although  built  up  on  a  definite  plan,  when 
viewed  from  the  standpoint  of  the  morphologist  alone, 
the  individual  variations  in  the  form  of  the  body,  slight 
though  they  be,  are  yet  so  numerous  as  to  dispel  once 
and  for  all  any  notion  that  there  is  an  ideal  of  human 
form  which  can  be  described  in  so  many  words.  Of 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.        7 

course  there  are  some  who, "  framed  in  the  prodigality  of 
nature,"  seem  to  approach  to  that  ideal  which  we 
associate  with  the  beautiful,  just  as  there  are  others  so  ill- 
fashioned,  "  cheated  of  feature  by  dissembling  nature, 
deformed,  unfinished,"  as  to  excite  in  the  beholder  feelings 
of  quite  an  opposite  nature.  And  yet  both  may  equally 
enjoy  all  that  we  know  as  health,  and  indeed  the  latter 
may,  like  the  mis-shapen  Richard,  be  endowed  with  a 
mental  and  a  bodily  vigour  far  surpassing  the  former. 

Our  subject  then  being  "  Personal  Appearances  "  in 
their  widest  sense,  there  is  no  need  to  dwell  upon  indi- 
vidual variations ;  but  dealing  with  the  matter  broadly, 
we  shall  have  to  ascertain  what  it  is  that  contributes  to 
the  form,  size,  and  colour  of  the  body,  and  what  is  the 
significance  of  departures  from  the  normal  in  these  re- 
spects. The  subject  is  a  wide  one.  We  can  but  touch 
upon  its  threshold. 

CHAPTER  I. 

THE    FORM    AND    SIZE   OF   THE    HUMAN    BODY. 

THOSE  animals  which  come  nearest  to  man  in  physical 
conformation  have  at  all  times  been  objects  of  interest 
and  of  study.  Their  habits  of  life,  no  less  than  their 
bodily  structure,  have  been  investigated  so  far  as  oppor- 
tunities have  occurred,  and  even  their  mental  attributes 
weighed  in  the  balance  with  those  shown  to  be  possessed 


8        PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

by  the  lowest  of  mankind,  and  not  always  to  the  advantage 
of  the  latter.  In  outward  conformation  the  tail-less  anthro- 
poid ape  bears  striking  resemblance  to  his  human  fellow- 
creature,  and  even  in  details  of  anatomical  structure  the 
differences  are  so  slight  as  hardly  to  amount  to  generic 
distinction  zootomically  speaking.  The  precise  points 
at  which  the  anatomy  of  man  touches  that  of  the  lower 
animals  are  very  numerous.  The  grosser  and  more  obvious 
differences  are  those  which  relate  to  the  hairy  covering 
of  the  body  in  apes  as  contrasted  with  man's  comparative 
bareness,  the  relative  proportions  of  the  limbs  to  the 
trunk,  the  comparative  size  of  the  skull  or  brain-case,  to 
that  of  the  face,  and,  lastly,  the  erect  stature  of  man  and 
the  consequent  modifications  in  and  development  of  the 
lower  limbs.  The  following  table,  from  Professor  Huxley,* 
shows  at  a  glance  the  difference  between  the  length  of 
the  bony  skeleton  of  the  extremities  compared  with  that 
of  the  spine.  The  spinal  column  is  taken  as  i  oo  : — 

Man- 
Male  Female  Gorilla.    Chimpanzee.      Orang. 
Bosjesman.  Bosjesman. 

Arm                  78  80  115  96  122 

Leg           .     no  117  96  90  88 

Hand                26  26  36  43  48 

Foot   .      .       32  35  41  39  52 

It  will  be  seen  that   the   upper  limb   in  these  three 
anthropoid  apes  is  relatively  longer  than  the  lower,  whereas 

*  *  Man's  Place  in  Nature.'     London,  1860,  p.  71. 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.        9 

in  the  Bosjesman  the  reverse  holds.  In  fact,  in  these 
apes  the  foot  is  used  largely  as  a  prehensile  organ,  and 
the  usual  mode  of  progression  is,  not  in  the  erect  posture, 
but  in  the  semi-erect,  or  even  on  all  four  limbs. 

The  erect  posture  of  man  largely  modifies  his  form  by 
calling  into  play  certain  muscles  which  become  more 
developed  in  him  than  in  animals.  The  muscles  of  the 
spine,  and  all  those  in  front  of  and  behind  the  thigh  which 
are  employed  in  moving  the  lower  limbs  in  progression 
are  thus  markedly  developed,  and  their  development 
forms  an  integral  part  of  the  contour  of  the  body.  But 
mere  muscularity  alone  does  not  suffice  to  conceal  the 
angularities  of  the  bony  framework  to  which  the  muscles 
are  attached,  or  at  any  rate  does  not  lead  to  the  appear- 
ance of  the  fine  curves  and  rounded  outlines  of  the 
human  form.  All  the  deficiencies  in  this  respect  are 
supplied  by  the  soft  fatty  tissue  which  underlies  the  skin 
filling  up  spaces  left  between  muscles,  and  concealing 
bony  prominences.  There  are  thus  three  factors  contri- 
buting to  the  form  of  the  body — bone,  muscle,  and  fat ; 
and  a  more  detailed  description  of  each  of  these  and  of 
their  arrangement  is  necessary  before  treating  of  the 
modifications  they  undergo,  and  the  consequent  changes 
in  the  general  form  of  the  body. 

The  regions  into  which  the  body  is  divisible  are,  head, 
trunk,  and  extremities.  The  head,  containing  the  brain 


10      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

and  bearing  the  sensory  organs  (which,  with  the  jaws  and 
mouth,  go  to  form  the  face),  is  largely  bony,  the  soft  parts 
being  very  slightly  developed  over  the  head  proper,  but  to 
a  greater  degree  over  the  face.  The  trunk,  divisible  into 
neck,  chest,  abdomen,  and  pelvis,  has  its  form  laid  down 
in  bone,  which  in  the  neck  and  abdomen  is  represented 
in  the  spine  only,  in  the  chest  by  the  ribs,  which  attached 
to  the  spine  behind  and  the  breast-bone  in  front  form  the 
walls  of  the  thoracic  cage  in  which  are  contained  the 
lungs  and  heart,  with  the  air  passages  and  blood-vessels 
connected  with  them,  as  well  as  the  gullet  passing  on 
its  way  to  the  stomach.  The  chest  cavity  is  separated 
from  that  of  the  abdomen  by  a  muscular  septum,  the 
diaphragm ;  and  contained  in  the  abdomen  are  the  organs 
of  digestion,  assimilation,  urinary  excretion,  and  others. 
The  lateral  and  front  walls  of  the  abdomen  are  soft  and 
pliable,  being  wholly  composed  of  skin,  subcutaneous 
fat,  and  muscular  layers.  Lastly,  the  pelvis  is  flanked  on 
each  side  by  the  greatly  expanded  haunch-bones  to  which 
the  bones  of  the  lower  extremity  are  attached.  The 
four  limbs,  subdivided  into  segments  and  terminating  in 
the  hands  and  feet,  are  connected  to  the  trunk  by  muscles 
and  ligaments  binding  the  joints. 

The  Skeleton.— The  bony  skeleton  (Fig.  i*)  or  frame- 

*  For  this  and  for  many  of  the  other  illustrations  we  are  indebted 
to  Mr.  H.  E.  Cree. 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       II 


work  consists  of  two  hundred  separate  bones,  eighty-three 
of    which     are    in    pairs,  JTIG 

and  those  that  are  single 
are  symmetrically  shaped 
and  could  be  divided 
into  two  equal  and  similar 
halves.  The  bones  forming 
the  head  or  skull  are  ar- 
ranged into  those  which 
form  the  cranium  proper  and 
those  which  enter  into  the 
face.  The  cranium  or  brain- 
case  rests  upon  the  spinal 
column  by  articular  surfaces. 
Its  roof  and  sides  are  formed 
by  several  flattened  bones, 
which  in  the  adult  are  firmly 
interlocked  one  with  another. 
Although  expanded  above, 
at  the  base  of  the  skull,  the 
bones  are  compact  enough, 
and,  except  for  the  numerous 
perforations  to  allow  of  the 
passage  of  nerves  from  the 
brain  and  of  blood-vessels,  and  a  large  aperture  below 
*  Adult  male  human  skeleton. 


12       PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 


FIG.  2* 


for  the  upper  part  of  the  spinal  cord,  which  is  con- 
tinuous with  the  brain, — the  brain-case  is  a  closed  box. 
In  front  of  the  cranium  is  the  face,  the  broad  features 
of  which  are  laid  down  in  the  numerous  bones  entering 
into  its  composition ;  bones  to  complete  the  eye-sockets, 
to  form  the  foundation  of  the  nose,  to  give  the  pro- 
minence to  the  cheek,  and  to  form  the  upper  jaw  and 
palate ;  whilst  articulated  to  the  temporal  bone  is  the 
lower  jaw,  which  in  the  adult  is  squarish  in  front,  and 
is  acted  on  by  powerful  muscles  for  its  closure  (Fig.  2). 

The  spinal  or  vertebral  column, 
or  backbone,  consists  of  a  number 
of  bones  called  "  vertebrae,"  joined 
together,  and  capable  of  a  certain 
amount  of  movement,  which  gives 
flexibility  to  the  whole  column.  In 
the  neck  these  are  seven  in  number, 
and  here  their  movement 'is  greatest. 
In  the  dorsal  m  region  there  are 
twelve,  each  of  them  bearing  a  rib 
on  each  side ;  then  come  five  larger 
lumbar  vertebrae,  and  four  more  fused  together  into  one 
bone,  the  sacrum,  and,  lastly,  three  rudimentary  bones, 
the  relic  of  the  tail.  The  cervical,  dorsal,  lumbar,  and 
sacral  consist  of  an  anterior  solid  part  or  body,  and  an 
*  Adult  male  human  cranium. 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       13 

arch  of  bone  behind,  with  a  projection  in  the  middle 
line,  so  that  when  united  there  is  a  channel  through  the 
whole  of  them,  which  lodges  the  spinal  cord,  passing 
from  the  brain.  The  shape  of  each  bone  varies  slightly 
from  its  fellow,  and  very  much  according  to  the  region 
in  which  it  is  placed,  so  that  the  width  of  the  column  is 
greatest  in  the  lumbar  region,  where  the  bones  are 
larger  and  deeper.  United  by  fibrous  bands  or  liga- 
ments, which  yet  allow  of  their  movement,  they  form  the 
whole  column,  which  is  not  straight,  but  is  curved  slightly 
forwards  in  the  neck,  backwards  in  the  back,  and  again 
forwards  in  the  lumbar  region. 

There  are  twelve  ribs  on  each  side  of  the  chest ;  each 
of  these  articulates  with  the  spinal  column  behind,  and  is 
capable  of  an  upward  movement  at  the  joint.  The  first 
rib  is  flattened  from  above  down,  and  is  comparatively 
short.  It  passes  from  the  first  dorsal  vertebra  to  join  the 
upper  part  of  the  breast-bone  or  sternum,  a  flattened, 
sword-shaped  bone  which  completes  the  chest  in  front. 
The  other  ribs  are  flattened  chiefly  from  side  to  side ;  six 
of  them  are  in  connection  with  the  sternum  in  front  by 
means  of  cartilages  which  are  about  two/  inches  in  length, 
and  in  shape  exactly  like  the  bony  rib.  The  next  three 
ribs  are  attached  by  their  cartilages,  not  directly  to  the 
sternum,  but  to  one  another;  whilst  the  eleventh  and 
twelfth  ribs — the  latter  shorter  than  the  former — are  quite 


14      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

free   from  anterior  attachments,  and   are   hence   called 
"  floating  ribs." 

The  bones  of  the  upper  extremity  consist  in  the  large 
single  arm-bone  or  humerus,  the  upper  extremity  of 
which  is  rounded  and  fits  into  a  socket  in  the  blade-bone 
or  scapula — a  flattened  bone,  which  rests  over  the  upper 
ribs  on  the  back,  and  can  move  over  them  for  some 
distance ;  a  curved  bone  forming  a  prominent  feature  at 
the  top  of  the  chest — the  "  collar-bone  "  passes  from  the 
scapula  to  the  sternum.  The  arm-bone  is  joined  at  the 
elbow  by  a  hinge  joint  with  the  bones  of  the  forearm, 
or  rather  with  the  ulna,  which  alone  enters  into  the 
elbow-joint.  The  ulna  is  thicker  at  its  upper  extremity, 
where  it  forms  the  prominence  of  the  elbow,  than  at  its 
lower ;  its  fellow,  the  radius,  on  the  outer  or  thumb 
side  of  the  forearm,  articulating  with  the  ulna  above, 
and  capable  of  rotation,  alone  bears  the  wrist.  Then 
comes  the  wrist-joint  and  a  series  of  small  bones,  eight  in 
all,  forming  the  wrist ;  to  these  succeed  five  long  bones 
forming  the  framework  of  the  hand,  and  upon  them  are 
articulated  the  finger-bones  or  phalanges,  of  which  there 
are  in  all  fifteen,  three  to  each  finger  and  two  to  the  thumb. 
Each  successive  lower  segment  is  smaller  than  the  upper, 
the  terminal  phalanx  being  expanded  at  the  extremity 
where  the  nail  is  borne.  The  length  of  the  fingers  depends 
upon  the  development  of  these  bones,  and  the  long,  taper- 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       15 

ing  fingers,  and  small  hand  of  the  high-born  lady  owe 
their  shape  to  the  delicately-formed  skeleton ;  just  as  the 
broad  and  short  hand  and  clumsy-looking  fingers  of  the 
rustic  are  due  to  his  coarser  and  broader  bones.  Notice 
that  the  second,  or  middle  finger,  is  the  longest ;  that  as 
a  rule  the  third,  or  ring-finger,  is  longer  than  the  first, 
but  not  always,  and  that  the  fourth  is  shortest  of  all. 

The  bones  of  the  lower  extremity  resemble  somewhat 
those  of  the  upper.  The  great  hip  bones,  which  are 
united  to  the  sacrum  behind,  and  to  one  another  in  front, 
represent  the  shoulder-blades,  and  each  bears  a  socket 
for  the  reception  of  the  upper  end  of  the  thigh  bone. 
This  single  bone,  called  the  femur,  is  succeeded  at  the 
knee  joint  by  two  bones,  one  large  and  massive,  and 
prismatic  in  shape — the  tibia — which  comes  close  under 
the  skin  in  front  and  forms  the  shin.  The  other  is 
slender,  and  passes  on  the  outer  side  of  the  tibia,  without 
entering  into  the  knee  joint,  and  flanks  the  outer  side 
of  the  ankle.  Then  the  bones  of  the  foot,  seven  in 
number,  interlocked  into  one  another,  one  forming  the 
heel,  and  bearing  on  its  upper  surface  the  square-shaped 
bone  which  articulates  with  the  tibia  to  form  the  ankle 
joint.  Then  in  front  of  this  a  boat-shaped  bone,  and 
then  a  series  of  four  small  wedge-shaped  bones,  which 
in  their  turn  articulate  with  five  long  bones  forming  the 
front  part  of  the  foot,  and  these  again  with  the  phalanges 
2 


1 6      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

of  the  toes,  stunted  and  small  in  comparison  with  those 
of  the  fingers.  One  other  bone  should  be  mentioned  in 
the  lower  limb — the  knee-cap,  which  is  visible  under  the 
skin,  and  in  front  of  the  knee  joint. 

In  the  disease  of  early  life  called  Rickets,  when  the 
skeleton  is  unnaturally  soft, — the  yielding  bones  of  the 
thigh  and  leg  give  way  under  the  weight  of  the  child  when 
it  attempts  to  walk,  and  extreme 
and  permanent  deformity  may 
result  unless  the  child  is  kept 
off  its  legs.  Thus  the  thigh 
bone  curves  forwards,  and  out- 
wards, and  the  leg  bones, 
especially  the  larger  one,  bend 
forwards,  and  bowed  legs  and 
"  knock-knees  "  (see  Fig.  3) 
result.  Happily  the  soft  and 
yielding  nature  of  the  bones 
allows  of  appliances  early  had 
recourse  to  effecting  the  straightening  of  the  limb ;  but 
unless  such  measures  be  taken,  and  if  the  child  continues 
to  walk,  the  deformity  will  be  increased,  and  as  the 
bones  grow  firm  will  be  borne  by  it  throughout  life. 

Such  in  merest  outline  is  the  bony  framework  of  the 
skeleton.  .  It  is  completed  by  the  union  of  the  bones  in 
*  Ricketty  deformity  of  bones  of  lower  limbs. 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       I  7 

joints,  which  are  of  various  forms  and  construction  in 
accordance  with  the  movements  they  have  to  subserve. 
Essentially,  a  joint  consists  in  the  two  ends 'of  the  bones 
which  enter  into  its  formation,  and  which  are  covered  by  a 
layer  of  cartilage,  a  sac,  secreting  fluid  which  bathes  the 
surfaces  of  the  cartilages,  and  in  fibrous  bands  or  ligaments 
protecting  these  structures,  and  serving  to  keep  the  bones 
in  apposition  and  to  limit  their  movements.  The  expanded 
ends  of  the  bones  entering  into  the  joints  add  to  the 
diversity  of  the  form  of  the  body,  and  alteration  in  these 
joints  themselves  gives  rise  to  conspicuous  deformities. 

The  Muscles. — The  skeleton,  bound  together  and  com- 
pacted by  the  ligamentous  structures,  is  clothed  with 
muscles,  which  are  structures  of  flesh  endowed  with  the 
power  of  contracting,  and  by  their  contraction  pulling  on 
the  bones  to  which  they  are  attached,  and  thus  subserving 
the  motion  of  the  body.  According  to  their  develop- 
ment, so  do  these  muscles  play  a  large  part  in  producing 
the  outlines  of  the  body,  and  their  bold  configuration  is 
well  reproduced  in  the  sculptures  of  antiquity.  Those 
muscles  which  are  most  wanted  for  the  support  of  life, 
and  for  locomotion,  are  the  most  developed,  e.g.  those 
of  the  lower  limbs. 

Besides  contributing  largely  to  the  mere  contour  of  the 
frame,  the  muscles  have  an  important  part  to  play  in 


1 8      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

maintaining  the  body  in  the  erect  position.  The  whole 
framework  of  the  body  is,  as  we  have  seen,  composed  of 
a  large  number  of  separate  parts.  Each  of  these  parts 
has  relations  with  others,  and  in  many  regions  one  can  be 
moved  on  the  other  by  means  of  muscular  action. 

There  is  moreover  a  state  of  equilibration  between 
the  muscles  performing  opposite  kinds  of  movement ; 
and  so  long  as  the  muscles  are  in  a  state  of  tonicity, 
and  so  long  as  the  one  set  bears  its  due  amount  of  work 
as  compared  with  the  other  set,  so  long  is  this  equi- 
libration maintained. 

This  may  be  readily  illustrated  by  the  part  played 
by  the  muscles  placed  before  and  behind  the  spine,  in 
maintaining  the  erect  posture  of  the  body.  The  position 
is  kept  up  without  effort,  without  even  consciousness, 
by  the  healthy  man  whose  muscles  are  well  balanced  and 
in  good  "tone."  It  may  be,  however,  that  the  same 
man  after  a  long  day's  work  over  a  desk,  in  an,  ill-venti- 
lated city  office,  no  longer  presents  that  supreme  un- 
consciousness of  his  muscles  and  their  action,  and 
the  stoop  of  his  shoulders  and  bent  head  demonstrate 
to  others  that  the  balance  is  no  longer  kept,  that  the 
tonicity  of  the  morning  has  passed  off,  and  the  wearied 
muscles  are  no  longer  on  the  watch.  And  so  it  is  when 
in  sleep  the  muscles  are  relaxed  and  gravity  asserts  its 
force,  so  that  the  head  falls  forward  by  its  own  weight, 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       19 

no  longer  restrained  by  the  passive  counteraction  of  its 
"  extensor  "  muscles.  It  may  be  mentioned  in  passing, 
that  so  little  is  there  any  effort  required  to  maintain  the 
body  erect,  that  it  is  a  sign  rather  of  weakness  than 
strength  in  anyone  who  exercises  an  effort  to  do  this. 
This  may  seem  paradoxical,  but  it  is  nevertheless  the 
case;  and  he  who  walks  "bolt  upright"  with  his  chin 
in  the  air  and  his  back  as  rigid  as  a  plank,  is  often 
not  a  strong,  but  a  weak  man. 

In  consequence  of  this  it  happens  that  various  de- 
formities arise  from  the  equilibrium  between  opposing 
muscles  being  destroyed  from  weakness  or  palsy  of  the 
one  set,  or  by  the  over-action  of  the  other  set.  For 
instance  u  wry-neck,"  which  consists  in  the  head  being 
permanently  fixed  in  a  position  inclined  to  one  shoulder^ 
or  its  continual  spasmodic  movement  in  that  one  di- 
rection, is  due  to  the  contraction,  or  over-action  of  the 
muscle  causing  that  movement  not  being  balanced  by  its 
opponent ;  or  if  the  muscles  of  expression,  those  of  the 
face,  be  palsied  on  one  side,  the  mouth  appears  drawn 
up  and  out  to  the  opposite  side,  an  appearance  exag- 
gerated by  calling  the  muscles  into  action  as  in  laughing; 
or,  again,  in  "  squinting,"  we  have  an  example  of  weak- 
ness or  palsy  of  one  or  more  of  the  six  small  muscles 
moving  the  eye-ball  preventing  the  movement  of  the  eye 
in  their  direction  of  action,  so  that  the  two  eyes  no 


20      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

longer  move  in  concert,  and  lose  their  parallel  action. 
Change  of  form  is  also  obvious  enough  from  wasting  of 
particular  groups  of  muscles.  We  may  only  instance  the 
flattening  of  the  back  of  the  forearm  in  lead-palsy,  where 
the  muscles  which  bend  the  hand  backwards  are  especially 
attacked,  so  that  the  hand  falls  and  cannot  be  raised — 
the  condition  known  as  "  wrist-drop." 

Then  again,  weakening  of  the  muscles  of  the  back  (as 
produced  by  enforced  sitting  on  benches  without  support 
to  the  back)  is  one  cause  of  what  is  called  lateral  cur- 
vature of  the  spine,  where  the  curve  to  one  side  which 
the  spine  has  in  the  loins  is  greatly  increased,  so  much 
so,  that  the  shoulder  on  the  side  to  which  the  curve  is 
directed  is  lower  than  its  fellow;  and  a  curve  in  the 
opposite  direction,  causing  projection  of  the  blade-bone, 
forms  in  the  dorsal  region. 

Club-foot  is  in  a  large  majority  of  cases  due  to  mus- 
cular defect — a  defect  which  may  be  present  to  a'  certain 
degree  at  birth,  or  which  may  arise  from  an  unnoticed 
paralysis  in  early  childhood.  The  most  common  form  of 
this  is,  that  where  the  heel  is  raised,  and  the  subject  walks 
not  on  the  sole  but  on  the  toes,  or  more  frequently  on  the 
side  of  the  foot.  The  strong  tendon  which  passes  from 
the  calf  muscle  to  the  heel  is  in  such  cases  contracted,  the 
muscles  themselves  being  wasted  from  their  long  enforced 
inactivity,  so  that  the  leg  appears  small  and  shrivelled. 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       21 

Nor  simply  from  bearing  weight  do  ricketty  bones  give 
way.  The  muscles  that  are  attached  to  them  act  as 
powerfully  in  producing  their  distortion,  as  may  be  seen 
in  the  thigh  bones  (Fig.  3),  in  the  collar  bones,  and  in 
those  of  the  upper  limbs,  the  powerful  muscle  which 
passes  from  the  shoulder  blade  to  be  attached  to  the 
humerus  on  its  outer  surface  often  causing  considerable 
distortion  of  that  bone. 

Such  are  some  of  the  changes  of  form  which  muscles 
give  rise  to ;  those  depending  upon  great  muscular  de- 
velopment are  too  obvious  to  be  detailed,  the  fact  need 
only  be  stated  that  the  more  work  a  muscle  is  called  on 
to  perform  the  larger  it  grows,  and  as  it.  grows,  it  must 
proportionately  modify  the  form  of  the  body. 

The  Fatty  Layer. — Lastly,  beneath  the  skin  is  the  layer 
of  fatty  tissue  which  is  in  very  variable  amount  in  different 
sites,  being  for  instance  wanting  in  the  scalp,  which  is  in 
contact  with  the  skull,  but  abundant  in  the  face  of  a  well- 
nourished  individual,  concealing  the  prominent  cheek- 
bones. Fat  also  occurs  in  the  interior  of  the  body  around 
organs,  but  this  really  does  not  concern  us  here.  How- 
ever, it  may  be  mentioned  that  the  eyeball  rests  on  a 
cushion  of  fat ;  and  the  sunken  eye  of  a  wasted  person  is 
due  to  diminution  in  this  cushion.  In  addition  to  this,  the 
natural  fulness  of  the  skin  is  further  due  to  the  presence 


22      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

throughout  it,  and  the  textures  underlying  it,  of  blood- 
vessels full  of  blood ;  this  has  a  great  influence  on  the 
shape— as  seen  by  the  shrivelled  aspect  of  a  part  which 
is  deprived  of  blood  from  any  cause,  e.g.  cold,  which 
causes  contraction  of  the  small  arteries,  and  lessens  the 
supply  of  blood  to  the  part. 

The  general  form  is  dependent  on  the  due  relation  of 
all  these  parts,  and  modification  in  either  will  lead  to  pro- 
portionate change  in  shape  of  the  body.     The  shape  of 
FlG  4*  the  head,  as  a  whole,  is  deter- 

mined by  the  form  of  the  skull, 
as  is  well  exemplified  in  the 
negro  (Fig.  4),  where  the  pro- 
tuberant and  prominent  lips  are 
attached  to  the  projecting  upper 
jaw-bones  — -  the  prognathous 
form  of  skull. 

It  may  be  observed  that  there 
is  a  perfect  bilateral  symmetry 
in  the  whole  body — a  symmetry  which  is  not  only  apparent 
on  the  exterior,  but  obtains  in  the  skeleton,  and  to  a  great 
extent  in  the  disposition  of  the  internal  organs. 

We  may  now  rapidly  enumerate  the  leading  changes  in 
form  undergone  by  the  body  at  different  periods  of  life. 
*  Skull  of  negro,  showing  prognathism. 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       23 

In  infancy  the  head  is  large  in  proportion  to  the  chest, 
and  the  bones  of  the  cranium  are  not  fully  ossified,  but 
are  separated  from  one  another  by  membrane,  which, 
between  the  frontal  and  parietal  bones,  and  between  the 
latter  and  the  occipital,  leaves  a  considerable  interval. 
Then  the  face  is  small  in  proportion  to  the  cranium,  and 
the  lower  jaw,  instead  of  having  an  angle  at  its  pos- 
terior extremity,  which  in  the  adult  is  F  * 
almost  a  right  angle,  is  nearly  horizontal 
(Fig.  5).  The  skeleton  is  incompletely 
ossified,  the  muscles  small  and  ill- 
developed,  the  contour  of  the  body 
being  chiefly  made  up  by  the  excessive 
fatty  layer  which  underlies  the  skin. 
The  neck  is  short;  the  chest  prominent,  narrow,  and 
short ;  and  the  abdomen  large  and  capacious,  whilst  the 
spine  is  nearly  straight,  and  the  lower  limbs  propor- 
tionately short.  In  youth  the  chief  change  lies  in  the 
greater  development  of  the  lower  limbs,  the  greater 
proportional  increase  in  the  size  of  the  chest,  and  cor- 
responding diminution  of  the  head  and  abdomen.  The 
spine  now  forms  a  double  curve.  In  adult  life,  when 
all  the  skeleton  is  firmly  ossified,  trie  jaw  is  square,  its 
angle  almost  a  right  angle  (Fig.  2),  the  chest  fully  ex- 
panded, the  lower  limbs  well  developed.  In  old  age  the 
*  Skull  of  infant. 


24      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 


stature  is  less,  the  neck  broad,  and  shoulders  rounded ; 
the  bones  are  more  fragile,  the  rib  cartilages  fixed  and 
hardened;  the  lower  jaw,  from  loss  of  teeth,  reverts  some- 
what to  the  infantile  form  (Fig.  6),  whilst  the  chin  appears 
FlG  6  *  more  prominent  and  approxi- 

mates to  the  sharpened  pro- 
jecting nose;  and  the  skin 
hangs  loosely,  and  in  folds 
and  wrinkles,  in  proportion 
as  the  fatty  layer  has  de- 
creased and  the  muscles  have 
diminished. 

Of  the  differences  in  the  two  sexes  suffice  it  to  note 
that  the  average  stature  of  women  is  less  than  that  of 
men ;  that  in  the  former  there  is  a  greater  tendency  to 
the  growth  of  the  subcutaneous  fat,  and  that  the  skeleton 
of  the  pelvic  region  is  modified  so  that  the  hips  are  wider 
in  the  female  than  the  male. 


CHAPTER  II. 

CHANGES  IN  THE  FATTY  LAYER. 

HAVING  thus  as  it  were   propounded   the   bases   upon 
which  the  form  of  the  body  depends,  let  us  consider 

*  Skull   of  aged  person.    It  is  unusually  long  from  before  back- 
wards in  the  above  figure. 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.      25 

the  variations  which  this  form  undergoes.  Some  of  these 
are  irremediable  in  the  individual,  stamped  upon  him  by 
inheritance  ;  others  are  the  effects  of  declared  disease  de- 
ranging the  economy  ;  others  again  arise  from  the  perverse 
practices  of  mankind  in  the  matter  of  clothing,  or  by  the 
equally  perverse  pursuit  of  certain  modes  of  life  and 
labour  which  cramp  and  distort  the  frame,  disabling  the 
individual  for  the  comfort  of  the  community.  Such  and 
many  more  comprise  a  long  catalogue  of  effects,  some  of 
which  are  compatible  with  good  bodily  vigour,  whilst 
others  can  only  be  regarded  as  warning  signs,  if  not 
actual  indications  of  defective  health. 

Perhaps  the  most  convenient  way  of  dealing  with  the 
matter  will  be  to  discuss  seriatim  the  effects  which  arise 
from  changes  occurring  in  each  part  of  the  framework, 
and  show  how  deficiency  here  or  redundancy  there  may 
be  brought  about,  and  to  indicate  what  it  teaches. 

We  have  then  first  to  treat  of  changes  in  the  Fatty  Layer. 

It  is  impossible  to  say  where  leanness  ends  and  fatness 
begins,  just  as  it  is  impossible  to  mark  the  dividing-point 
between  any  other  two  opposed  states.  But  all  the  world 
knows  what  is  called  a  "  lean  "  figure,  just  as  it  can  point 
to  a  corpulent  one,  only  between  the'two  there  is  of  course 
any  amount  of  gradation.  In  the  absence  of  any  given 
standard  of  proportion  between  the  height  of  the  body 
and  its  girth,  we  need  not  attempt  a  strict  definition  of 


26      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

either  one  or  the  other,  but  must  be  contented  with  the 
general  statement  that  leanness  depends  on  a  deficiency 
in  the  soft  parts,  and  corpulence  upon  an  excess  of  the 
fatty  layer  especially.  Now  each  of  these  conditions,  even 
to  a  very  extreme  degree,  is  compatible  with  health. 
Many,  indeed,  if  not  born  lean,  yet  acquire  leanness 
because  they  inherit  the  disposition  to  it ;  these  are  the 
wiry  muscular  men,  and  the  angular  women.  To  have  a 
"lean  and  hungry  look"  does  not  by  any  means  ne- 
cessarily portend  that  the.  possessor  "  thinks  too  much." 
It  may  simply  mean  that  he  has  inherited  the  type  from 
his  parents,  and  were  he  now  submitted  to  the  close 
confinement  and  rich  fat-making  diet  of  a  Strasburg  goose 
it  is  doubtful  if  the  wanting  adiposity  would  ever  come 
to  round  the  angles  of  his  frame.  It  must  then  always 
be  borne  in  mind  that  deficiency  in  fat  is  not  a  sign 
of  disease,  unless  the  individual  has  been  previously  well 
nourished,  and  although  there  is  no  doubt  that  much  is 
claimed  for  the  influence  of  heredity  which  it  can  hardly 
bear,  yet  this  goes  for  a  great  deal  in  the  production 
of  a  spare  habit  of  body.  Many  other  factors,  however, 
help  in  its  production  ;  continued  muscular  activity  is 
a  well-known  counteracting  influence  against  the  over 
production  of  fat,  for  the  muscles  in  their  work  require 
nutriment,  taking  it  from  the  food,  which  unless  dis- 
posed of  in  this  way  would  go  to  add  to  the  general 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       27 

store  of  fat.  And  accompanying  with  such  exertion  there 
are  the  quickened  circulation  and  increased  activity  of 
respiration,  by  which  the  blood  is  more  rapidly  exhausted 
and  requires  more  frequent  renewal  than  when  the  body 
is  at  rest.  When  to  this  is  added  a  spare  but  sufficient 
diet,  and  especially  an  avoidance  of  malt  and  alcoholic 
drinks,  the  induction  of  a  lean  habit  is  more  and  more 
favoured.  There  can  be  no  doubt  also  that  equally  with 
muscular  activity,  continued  mental  exercise  will  hinder 
fat  production,  for  although  it  would  be  an  unfounded 
aspersion,*  frequently  disproved  in  fact,  that  fat  people 
have  sluggish  faculties,  yet  there  can  be  no  question  that 
severe  mental  application  tends  to  a  lean  habit,  and  that 
the  words  put  into  Caesar's  mouth  by  Shakespeare  in 
speaking  of  Cassius  have  some  measure  of  truth  in  them. 

It  may  be  pointed  out  here  that  as  a  rule  the  inhabi- 
tants of  tropical  climates  are  leaner  than  those  of  tem- 
perate or  frigid  zones,  and  the  probability  is  that  the 
former  make  less  flesh.  However,  there  are  many  ex- 
ceptions to  the  rule;  for  the  indolent  life  of  the  first 
named,  dwelling  in  a  land  "  where  it  is  always  afternoon" 
and  where  nature  in  her  luxuriance  i§  always  at  hand  to 
supply  his  physical  needs,  would  favour  rather  the  ten- 
dency to  fat  production  when  contrasted  with  the  more 
active  work  of  the  latter. 

One  more  point  about  lean  people  and  we  pass  them 


28  '  PERSONAL   APPEARANCES  IN  HEALTH  AND  DISEASE. 

by  for  the  more  interesting  group.  It  is  notorious  that 
persons  of  spare  habit  are  not  only  capable  of  resisting 
more  fatigue  than  others,  but  they  often  show  far  more 
resistance  to  the  inroads  of  disease.  This  is  especially 
the  case  with  acute  diseases,  e.g.,  fevers.  As  a  rule  there 
is  more  vitality,  more  ability  to  struggle  with  the  violent 
disorders  of  nutrition  in  such  diseases  among  spare 
people  than  among  the  stout,  so  that  a  lank  ungainly 
habit  has  its  compensation, — it  is  more  often  tenacious  of 
existence  than  the  apparently  but  not  really  more  robust 
frame. 

When  we  turn  to  the  opposite  condition  to  leanness 
we  find  ourselves  trenching  upon  the  borders  of  disease, 
for  that  beyond  a  certain  extent  corpulence  is  non-natural 
may  be  admitted,  and  that  it  is  dependent  on  defects  in 
the  working  of  the  animal  mechanism  is  highly  probable. 
In  infancy,  fat  production  is  paramount ;  the  food  of  the 
infant  is  rich  in  materials  for  its  formation,  and  although 
growth  is  proceeding  with  marvellous  rapidity,  yet  a  thin 
babe  is  an  abnormality,  a  witness  to  improper  feeding  so 
common  among  all  classes.  The  inert,  almost  vegetable, 
existence  of  the  suckling  infant  favours  this  storage  of  fat, 
and  its  plump  cheeks,  its  chubby  extremities  marked 
by  deep  furrows  at  their  flexures,  are  indications  of  this 
storage.  But  as  has  been  pointed  out,  even  in  this  early 
period  of  existence  the  production  of  fat  may  exceed  the 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       29 

normal,  and  trangress  the  bounds  of  health;  and  then  all 
the  forming  causes  tell  with  tenfold  vigour. 

But  as  growth  proceeds,  and  activity  takes  the  place  of 
inertness,  the  tendency  to  the  production  of  fat  is  lessened ; 
and  hence  it  is  that  a  fat  child  or  youth  is  rightly  regarded 
as  one  whose  nutrition  is  at  fault,  or  whose  diet  is  of  a 
kind  which  should  not  be  encouraged.  The  full  exercise 
of  the  body,  during  its  period  of  growth,  is  incompatible 
with  the  production  of  fat,  and  strongly  counteracts  what 
tendency  there  may  be  to  its  formation.  As  life  advances, 
and  the  period  of  growth  is  passed,  and  maturity  is 
yielding  before  the  advance  of  old  age,  then  the  lessened 
call  upon  the  expenditure  of  the  body  favours  the  accu- 
mulation of  fat,  and  we  reach  that  period  of  the  seven 
ages  when  corpulence  is  regarded  almost  with  reverence, 
and  even  desired  as  adding  dignity  and  importance. 

Of  the  causes  of  corpulence  that  which  is  predominant 
is  that  to  which  we  have  already  referred  with  regard  to 
leanness.  The  tendency  to  obesity  is  as  much  under  the 
influence  of  heredity  as  the  tendency  to  spareness.  It 
"  runs  in  families,"  and  it  can  as  little  be  avoided  as  a 
man  can  get  rid  of  his  features  or  the,  colour  of  his  hair, 
or  tendency  to  early  baldness,  or  any  of  the  thousand  and 
one  proclivities  which  he  derives  from  his  parents.  Vain 
indeed  is  the  effort  to  reduce  his  form  to  greater  comeli- 
ness. No  amount  of  abstinence  in  diet,  of  regulated  or 


30      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

even  excessive  exercise  will,  except  at  the  expense  of 
health,  rid  him  of  his  proclivity,  although  care  may  keep 
it  within  limits. 

There  are,  however,  many  subordinate  and  favouring 
causes  to  corpulence.  The  first  to  be  mentioned  is  that 
of  sex.  Undoubtedly  women  are  more  prone  to  this 
production  than  their  hardier  brothers.  Without  seeking 
for  an  explanation  of  this  fact,  it  is  better  to  accept  it  as 
a  fact,  true  from  the  beginning,  and  parallel  with  the 
facts  known  as  to  the  average  stature  of  the  sexes,  that 
women  have  more  fat  than  men. 

So  again,  the  time  of  life,  as  we  have  already  indi- 
cated, is  a  predisposing  cause  to  corpulence. 

But  there  are  other  causes,  not  indeed  often  if  ever 
sufficient  of  themselves  to  increase  the  amount  of  the  fat 
in  the  body,  fat  which,  be  it  remembered,  is  not  limited 
simply  to  the  exterior  as  we  are  now  considering  it,  but 
abundant  also  around  certain  organs  and  in  certain  tissues 
in  the  interior  of  the  body.  These  are,  first  and  foremost 
the  continued  consumption  of  rich  oleaginous,  starchy  or 
saccharine  food,  and  drinks,  such  as  malt  liquors  and 
alcohol.  Who  is  not  acquainted  with  the  typical  dray- 
man, whose  portly  figure  matches  well  with  the  rotundity 
of  the  barrels  on  his  dray,  and  the  plump  sturdy  horses 
between  the  shafts  ?  Physiologists  have  calculated  to  a 
nicety  the  number  of  ounces  of  nitrogenous,  carbo- 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       31 

naceous,  and  fluid,  material  that  is  necessary  to  be  the 
daily  food  of  man,  to  supply  his  normal  waste,  to  give 
the  amount  of  fuel  sufficient  to  keep  the  human 
mechanism  in  due  working  order.  All  over  and  above 
this  is  waste,  much  thrown  off,  much  also  stored  up  as 
fat  to  be  called  for  if  occasion  ever  require  it.  Hence 
regulating  diet  to  a  nicety,  by  cutting  off  excess  of  those 
foods  which  most  go  to  "  make  fat,"  and  such  liquors 
that  do  the  same,  was  the  gist  of  that  method  aiming  at 
the  cure  of  corpulence  propounded  to  Mr.  Banting  by 
the  late  Mr.  Harvey,  and  quoted  now  in  learned  medical 
treatises  as  the  system  of  "  Bantingism." 

Another  cause,  and  one  which  the  very  possession  of 
a  corpulent  habit  only  serves  to  perpetuate  and  extend, 
is  indolence — indolence  of  body  and  indolence  of  mind. 
To  take  things  easily,  "  to  laugh  and  grow  fat,"  to  do 
nothing  with  undue  expenditure  of  force  or  thought,  this 
is  one  of  the  main  causes  of  fat  production.  And  many 
people,  already  corpulent,  cannot  help  being  lazy.  It  is 
a  greater  effort  for  them  to  pursue  even  the  ordinary 
avocations  of  life,  how  much  more  its  more  arduous 
and  less  necessary  exertions  !  Lack  of  energy  is  then 
both  cause  and  consequence,  and  as  'the  fat  grows  the 
muscle  wastes;  and  to  "make  flesh"  is  a  phrase  which 
often  should  more  properly  be  used  in  the  opposite 
sense. 


32       PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

Other  favouring  conditions  for  the  development  of  fat 
are  equability  of  temperament,  the  cold,  impassive 
"  phlegmatic  "  rather  than  the  excitable  and  nervous ;  and 
an  impoverished  condition  of  blood  whereby  its  functions 
are  ill-performed,  and  that  function  of  getting  rid  of  waste 
material  also. 

Corpulence  is  an  attribute  which  is  by  no  means 
unmixed  with  the  reverse  of  blessings.  Its  greatest  evil  is 
that  its  possessor  when  attacked  by  acute  disease  is  less 
fitted  to  contend  against  it  than  his  sparer  neighbour. 
This  may  be  in  part  because,  as  we  have  seen,  habits 
unhealthy  in  themselves  are  so  often  at  the  foundation  of 
the  corpulent  state.  But  even  apart  from  this  and  from 
the  difficulties  the  fat  man  has  to.  contend  with  when  laid 
low  by  illness,  it  must  be  generally  admitted  that  his  power 
of  resistance  to  acute  inflammatory  disorder  is  but  slight. 

We  come  now  to  conditions  that  are  abnormal,  both 
in  diminution  and  in  excess  of  the  subcutaneous  fatty 
layer.  Many  diseases,  nay  most,  are  accompanied  by 
"loss  of  flesh."  In  some  affections  this  wasting  takes 
place  rapidly — e.g.,  in  the  acute  febrile  diseases ;  in  others 
it  is  slowly  progressive.  It  depends  upon  two  factors,  one 
excessive  consumption  of  tissue,  the  other  diminished  ca- 
pability of  assimilation  and  of  nutrition.  In  a  few  maladies 
both  these  factors  are  at  work;  with  a  chronic  wasting 
disease,  such  as  consumption,  it  is  the  latter  only  or 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       33 

almost  solely.  To  deal  first  with  the  latter  cause, 
viz.,  diminished  assimilation  of  food,  let  us  see  the 
effect  that  is  produced  by  starvation.  It  does  not  re- 
quire a  visit  to  a  famine-stricken  district  to  become 
acquainted  with  the  repulsive  details.  Examples  enough 
are  unfortunately  presented  daily  before  our  eyes,  where 
from  ignorance  of  the  simplest  rules  of  diet,  infants  are 
practically  starved,  although  apparently  highly  fed.  And 
it  is  in  infants  that  the  effects  of  deprivation  of  food, 
or  of  the  administration  of  such  food  which  cannot  be 
assimilated,  and  therefore  cannot  subserve  nutrition,  is 
most  plainly  seen.  The  first  tissue  to  "go,"  and  that 
which  wastes  to  its  largest  extent  is  the  fatty  layer 
beneath  the  skin.  It  has  been  calculated  that  as  much 
as  93  per  cent,  weight  of  fat  can  be  lost  in  the  process 
of  starvation — a  degree  of  wasting  which  far  exceeds 
that  of  any  other  tissue  in  the  body.  It  is  as  if  this 
material  is  standing  in  reserve,  to  be  first  utilised  when 
either  food  is  withheld,  or  when  the  processes  of  dis- 
integration surpass  those  of  growth. 

The  rapidity  with  which  the  transition  from  the  fulness 
and  rotundity  of  health  passes  into  y  the  more  or  less 
highly  attenuated  condition  is  exemplified  in  several  affec- 
tions, which,  being  of  an  acute  character  and  accompanied 
by  considerable  discharges  from  the  blood,  e.g.,  cholera, 
drain  the  blood-vessels  and  take  away  fluid  from  them. 


34      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

And  these  effects  are  shown  more  rapidly  and  readily, 
although  perhaps  carried  to  a  less  extent,  in  individuals 
who  previously  were  well  nourished  or  even  corpulent. 
For  in  these  the  contrast  is  all  the  more  striking  than  in 
those  in  whom  from  the  slight  amount  of  adipose  tissue 
normally  present  there  is  already  the  appearance  of 
wasting.  Hence  it  is  that  the  appearances  of  ill-health 
are  best  seen  in  those  who  previously  had  the  greater 
appearance  of  robust  health,  and  the  sunken  cheek  and 
drawn  face  show  early  the  inroads  of  disease. 

In  acute  fevers  there  is  a  great  call  upon  the  stores  of 
nutriment, in  the  body,  and  much  waste  takes  place 
which  cannot  be  made  up  while  the  fever  process  lasts ; 
because  the  functions  of  digestion  and  assimilation  are 
perverted.  Hence  in  a  few  days  or  weeks  of  fever  the 
body  emaciates  to  a.  marked  degree.  Nor  is  the  wasting 
limited  to  the  fatty  layer.  As  in  starvation  this  doubtless 
is  the  first  to  be  used  up,  but  then  further  call  is  made 
upon  the  other  structures,  and  muscles  grow  thin  and 
flabby  too.  The  recovery  of  form  after ,  the  fever  has 
passed  away,  during  the  stage  of  convalescence,  is  chiefly 
by  the  reproduction  of  fat ;  for  it  requires  a  long  period 
of  careful  exercise  to  restore  the  muscles  to  their 
previous  natural  condition.  Indeed,  it  is  frequent  enough 
that  an  acute  and  wasting  fever  will  cause  such  per- 
manent alteration  in  the  nutrition  of  the  body  as  to  lay 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.      35 

the  foundation  for  a  condition  of  corpulence  to  which 
the  subject  was  previously  quite  a  stranger.  The  slower 
process  of  losing  flesh  that  occurs  in  chronic  wasting 
diseases  affects  the  same  parts,  and  depends  either  upon 
actual  starvation,  the  disease  involving  the  digestive 
organs,  or  upon  some  interference  with  the  natural 
transformation  of  food  into  tissue,  or  the  occurrence  of 
prolonged  discharges  impoverishing  the  blood. 

Mere  modifications  in  quantity  of  the  subcutaneous 
materials  are  not  the  only  causes  of  change  of  form  in 
the  soft  parts ;  abnormal  products  may  accumulate  in 
their  tissues  and  lead  to  change  of  shape.  This  is  seen, 
e.g.,  after  an  injury,  when  a  swelling  is  produced  by  the 
escape  of  blood  into  the  tissues ;  or  when  a  part  is 
inflamed.  Then  it  becomes  swollen  by  the  escape  not 
actually  of  blood  but  of  some  of  the  constituents  of  the 
blood,  and  may  even  go  on  to  form  a  limited  swelling  full 
of  matter,  an  abscess.  Or  tumours  of  all  kinds  may  give 
rise  to  local  derangements  in  shape.  But  there  is  a  con- 
dition, in  dropsy,  which  may  effect  a  change  in  the  whole 
body,  or  may  be  limited  to  one  part.  Here  the  serum  of 
the  blood  which  is  unduly  watery  escapes  into  the  tissues, 
and  replaces  the  fat;  and  the  skin  becomes  stretched 
and  smooth  in  proportion  to  the  amount  of  the  dropsy. 
Seen  to  its  greatest  extent  in  the  dependent  lower  limbs, 
where  the  fluid  naturally  gravitates,  it  may  appear  in  all 


36      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

parts,  as  in  the  loose  tissue  under  the  eyelids.  Many  con- 
ditions give  rise  to  this,  some  depending  on  local  disturb- 
ances of  the  circulation,  others  on  general  blood  conditions, 
and  thus  it  may  be  of  grave  and  serious  significance. 

Lastly,  in  the  subjects  of  long-standing  disease  of  the 
heart  or  of  the  chest,  there  occurs  often  what  is  called 
"clubbing"  of  the  extremities.  It  is  best  seen  in  the 
fingers,  the  tips  of  which  become  broad  and  rounded, 
especially  the  soft  palmar  surface.  But  the  same  club- 
bing may  be  seen  at  the  extremity  of  the  nose.  In  all 
cases  it  is  dependent  on  the  slowing  of  the  circulation 
which  takes  place  in  such  diseases,  so  that  there  is  an 
almost  permanent  condition  of  overfulness  of  the  minute 
blood-vessels  of  these  extremities. 


CHAPTER  III. 

CHANGES  IN  THE  BONY  FRAMEWORK. 

HAVING  sufficiently  alluded  to  changes  in  form  produced 
by  alterations  in  the  muscular  structures  (see  p.  17  and 
seg.),  and  in  the  fatty  layer  (see  p.  24  and  se#.)9  we  have 
to  consider  now  those  due  to  alterations  in  the  bones 
and  in  the  joints.  Changes  which  occur  in  the  shape 
of  the  skeleton  necessarily  entail  very  marked  deformity. 
Some  of  these  are  the  result  of  previous  muscular  failure, 
others  are  due  to  affections  of  the  joints,  others  to 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       37 

alterations  in  organs  contained  within  or  in  contact  with 
the  bony  structures,  and  others,  again,  to  altered  con- 
ditions of  the  bones  themselves,  arising  primarily,  and 
independently  of  any  previous  condition  of  contiguous 
parts.  When  a  bone  is  broken  there  may  or  may  not  be 
considerable  deformity ;  its  occurrence  depending  on  the 
nature  arid  extent  to  which  the  injury  has  taken  place, 
the  position  of  the  bone  itself  and  its  connection  with 
muscles.  In  consequence  of  this,  sometimes  most 
careful  scrutiny  will  fail  to  detect  that  a  bone  is  broken, 
whilst  at  other  times  the  whole  limb  may  be  bent  and 
the  injury  be  manifest  at  once.  Thus  a  rib  may  be 
broken,  but  no  external  change  in  shape  will  reveal  the 
fact  to  the  observer.  But  the  arm  or  thigh  may  be  frac- 
tured, and  the  amount  of  deformity  be  striking.  The 
more  oblique  the  fracture  is,  the  greater  the  resulting 
deformity  j  for  then  the  muscles  attached  to  the  fragments 
will  in  their  traction  on  each  pull  them  the  one  over  the 
other  and  so  lead  to  shortening  of  the  limb. 

Sometimes  when  the  two  fragments  of  a  broken  bone 
do  not  grow  together  again  naturally,  or  unite  in  a  dis- 
torted manner,  the  limb  remains  permanently  misshapen. 
But  even  where  the  union  is  natural  and  perfect,  an 
irregularity  in  the  shape  of  the  bone  itself  will  denote 
long  after  the  spot  where  the  junction  has  taken  place. 

The  main  cause  of  distortions  in  the  shape  of  the  bony 


38      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

framework,  and  therefore  of  the  whole  body,  is  the  disease 
of  infancy  called  rickets,  to  which  allusion  has  already 
been  made.  In  this  affection  the  whole  skeleton,  at 
its  period  of  most  active  growth,  when  the  soft  carti- 
laginous and  membranous  structures  which  are  ultimately 
to  become  firm  bone,  still  form  a  large  part  of  the 
framework,  suffers  from  lack  of  proper  material  for  the 
formation  of  bone,  and  grows  exuberantly  but  yet  not 
firmly,  and  the  evil  results  that  ensue  are  due  in  great 
measure  to  the  unnatural  softness  of  these  structures 
combined  with  their  great  abundance.  There  is  abundant 
material  to  form  bone,  but  it  is  bad  material ;  there  is 
active  growth,  but  it  is  a  perverted  activity. 

Some  of  its  effects  have  already  been  mentioned ; 
others  will  be  met  with  later  on.  One  of  these  effects  is  a 
curvature  of  the  spine,  not  to  one  side,  as  we  saw  resulted 
from  muscular  weakness,  but  a  bending  forwards,  giving 
the  appearance  of  the  spine  "  growing  out,"  as  it  is 
popularly  termed.  A  sharper  angle  in  this  direction, 
leading  to  considerable  deformity,  is  produced  by  actual 
disease  of  the  bones  of  the  spinal  column.  Such  curva- 
tures are  called  "  angular  curvatures,"  distinguishing 
them  from  the  " lateral"  bendings  before  mentioned. 
"  Knock-knees  "  and  "  bowed  legs  "  are  mostly  due  to 
rickets  (see  Fig.  3) ;  their  names  sufficiently  indicate  the 
deformities  they  produce. 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       39 

Any  account  of  the  changes  of  form  undergone  by  the 
body  would  be  incomplete,  even  in  a  general  sketch  like 
this,  without  some  mention  of  those  partial  but  frequently 
troublesome  and  permanent  distortions  which  arise  from 
affections  of  the  joints.  All  the  structures  entering  into 
the  composition  of  a  joint  may  at  one  time  or  another  be 
so  altered  as  to  lead  to  deformity.  Thus,  the  synovial 
sac  (see  p.  17)  may  become  distended  with  fluid,  and 
give  the  joint  a  swollen  rounded  appearance,  concealing 
entirely  the  natural  prominences  of  the  extremities  of  the 
two  bones  that  form  it :  or  the  fibrous  ligaments  surround- 
ing the  ends  of  the  bones  and  keeping  them  together 
may  be  swollen  and  altered  from  inflammation,  and  lead 
to  similar  swelling  and  alteration  of  the  other  soft  parts,  so 
as  completely  to  disguise  the  joint  and  render  it  more  or 
less  fixed.  Or  these  same  ligaments  may  be  shortened  and 
changed  by  disease  so  as  to  cause  one  bone  to  pass  beyond 
the  other,  and  produce  what  is  called  a  dislocation,  or  the 
dislocation  may  take  place  from  a  violent  injury,  without  any 
disease  of  the  joint,  and  lead  to  marked  deformity  of  the 
limb  at  the  part  of  the  displacement.  Or  the  ends  of  the 
bones  themselves  may  be  enlarged  and  the  seat  of  changes, 
which  permanently  cause  an  alteration  in  the  shape. 

As  to  simple  dislocation  from  injury,  it  may  be 
remarked  that  in  some  joints  this  cannot  take  place 
unless  bone  or  ligament  be  broken,  so  intimate  is  the 


40      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

interlocking  and  union  of  the  normal  parts.  But  on  the 
other  hand  there  are  joints  of  which  the  structure  admits 
of  ready  displacement.  When  a  joint  is  dislocated,  this 
is  shown  by  the  appearance  of  the  end  of  the  displaced 
bone  outside  the  socket,  or  separated  by  an  interval  from 
the  extremity  of  the  bone  with  which  it  was  previously 
in  contact.  There  is  then  such  a  deformity  as  results 
from  the  disappearance  of  the  rounded  end  of  the  bone 
at  one  place,  and  its  appearance  at  another,  a  depression 
occurring  where  formerly  there  was  a  projection. 

There  are,  however,  affections  of  the  joints  which  are 
common  enough  to  be  frequently  observed,  and  concern- 
ing which  a  few  words  must  here  be  spoken.  When 
from  a  twist  or  a  strain  the  ligaments  around  a  joint  are 
injured,  i.e.,  when  a  sprain,  as  it  is  called,  takes  place, 
there  is  always  a  certain  amount  of  inflammation  set  up. 
This  may  be,  and  indeed  if  the  sprain  be  a  severe  one,  is, 
preceded  by  considerable  bleeding  into  the  soft  parts 
around  the  joint,  and  a  consequent  bruise  over  the 
swollen  joint  is  added  to  the  other  evidences  of  injury. 
The  amount  of  force  exerted  on  the  joint,  or  the  direction 
of  the  force  has  not  been  enough  to  cause  a  dislocation, 
but  has  sufficed  to  stretch  or  rupture  ligaments  and  give 
rise  to  the  inflammatory  changes.  A  joint  may  become 
swollen  and  inflamed  from  other  forms  of  injury,  as  direct 
blows  or  wounds. 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       4! 

But  the  inflammations  set  up  by  diseases  such  as 
rheumatism  and  gout,  are  definite  in  their  characters, 
are  productive  of  great  alteration  in  the  form  of  the  joint, 
and  may  lead  to  changes  of  a  permanent  or  chronic 
character.  Let  us  watch  the  course  of  an  attack  of 
rheumatic  inflammation,  say  of  the  knee,  in  so  far  as  it 
causes  changes  of  form.*  The  pain  which  foretells  and 
which  indicates  the  seat  of  the  affection  is  soon  accom- 
panied by  perceptible  swelling;  there  is  a  rounded  fulness 
of  the  knee,  and  if  the  synovial  sac,  as  often  happens,  has 
a  large  quantity  of  fluid  secreted  into  it,  it  is  specially  dis- 
tended, and  bulges  beneath  and  on  each  side  of  the  knee- 
cap. The  surface  is  slightly  reddened,  a  redness  which 
fades  on  the  least  touch,  under  the  pressure  of  the  finger. 
Or  the  ankle  also  may  be  attacked,  and  the  bony  pro- 
jections on  each  side  of  it,  which  are  formed  by  the 
lower  ends  of  the  two  bones  of  the  leg,  are  concealed 
in  the  pufrlness  and  smoothness  of  the  inflamed  tissues. 
And  here  may  be  mentioned  the  fact,  not,  however,  without 
very  many  exceptions,  that  the  larger  or  middle-sized 
joints,  such  as  the  knee,  ankle,  wrist,  and  elbow,  are 
more  liable  to  be  inflamed  and  swollen  in  acute  rheuma- 
tism than  other  joints.  Still  frequently  enough  the 

*  It  must  be  distinctly  understood  that  the  purpose  of  this  little  book 
is  not  to  give  full  details  of  the  symptoms  of  any  disease,  except  in  so 
far  as  any  change  in  the  normal  form  is  brought  about  by  the  disease. 


42      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

smaller  joints  of  the  fingers,  and  less  frequently  those  of 
the  toes,  also  suffer.  In  a  short  but  variable  time,  a  few 
days  or  at  most  a  few  weeks,  the  swelling  subsides ;  with 
the  subsidence  of  the  inflammation,  the  joint  regains  its 
natural  shape  and  mobility.  But  the  rheumatism  may 
become  chronic,  and  then  the  swelling,  although  much 
diminished  in  extent,  will  yet  remain  a  very  long  time,  or 
may  indeed  never  wholly  disappear.  And  in  this  con- 
nection we  might  refer  to  an  inveterate,  nay  an  incurable 
and  painful  malady,  one  which  never  loses  its  hold  on 
the  sufferer,  but  advances  as  it  were  step  by  step  from 
joint  to  joint,  cramping  their  movements,  and  finally  en- 
tirely restraining  them,  and  leading  to  an  amount  of  dis- 
vtortion  and  alteration  in  and  around  them  which  entirely 
alters  their  form  as  well  as  their  function.  Under  its 
popular  cognomen  of  "  rheumatic  gout,"  or  its  scientific 
name  of  chronic  rheumatic  arthritis,  this  affection  is  known 
to  many.  Happily  of  not  very  frequent  occurrence,  its 
inveteracy  is  its  foremost  feature,  an  inveteracy  due  to 
the  slow  disorganising  changes  to  which  it^leads.  The 
knuckles  of  the  hand  become  rough  and  irregular,  and  the 
small  bones  of  the  fingers  are  displaced  from  their  natural 
relations  one  to  another.  The  nodular  prominences 
which  occur  over  and  above  the  normal  outline  of  the 
joint  are  due  to  the  production  of  fresh  bony  substance 
in  the  ligaments  and  from  the  bones  around  them,  while 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       43 

the  articulating  surfaces  of  the  bones  gradually  lose  their 
cartilaginous  covering,  and  become  slowly  altered  in 
shape.  In  consequence  of  the  fixing  of  the  joints,  the 
muscles  which  acted  on  them  are  no  longer  called  into 
play,  and  these  waste,  and  lead  to  a  shrinking  in  the 
bulk  of  the  limb  itself. 

The  changes  in  shape  of  the  joints  which  gout  produces 
are  somewhat  like  those  of  rheumatism.  (The  joints 
affected  are  as  a  rule  those  of  the  great  toe,  ankle,  fingers, 
but  even  knees,  wrists,  and  elbows.)  In  the  acute  form  of 
gout,  if  it  were  not  for  the  particular  joint  implicated  and 
collateral  evidence,  some  difficulty  might 
first  exist  in  determining  whether  the 
joint  swelling  were  due  to  rheumatism  or 
gout.  The  skin  over  a  gouty  joint  in  the 
acute  stage  is  glossy  and  shining,  and  when 
the  disease  becomes  chronic  the  defor- 
mations it  leads  to  are  marked  and  cha- 
racteristic. Around  the  affected  joint 
spring  up  nodulated  chalky  masses,  which  every  acute 
attack  leaves  behind,  until  hardly  a  joint  of  any  limb  but 
is  not  deformed  and  rendered  unsightly,  and  to  a  large 
extent  unserviceable  by  the  disorder. '  (See  Fig.  7.) 

There  are  of  course  other  diseases  affecting  joints,  than 
either  gout  or  rheumatism,  and  resulting  in  quite  as  much 

*  Extreme  deformity  of  hand  in  chronic  gout  (after  Garrod). 


44      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

destruction  of  the  joint  itself  and  distortion  of  the  limb. 
To  name  and  illustrate  only  one  of  them.  The  hip-joint 
is  frequently  attacked  with  inflammation  of  a  particular 
kind  in  children  of  what  is  called  strumous  constitution. 
In  its  early  stage,  this  disease  shows  itself  by  the  attitude 
of  .the  limb  almost  as  much  as  by  any  subjective 
pain.  The  child  fears  to  put  its  foot  down,  and  stands 
with  the  affected  leg  raised  and  turned  inwards,  so  that 
only  the  tips  of  the  toes  rest  on  the  ground  ;  and  actually 
there  may  be  some  shortening  of  the  limb,  whilst  if  the 
child  be  laid  on  its  face,  the  normal  fold  of  the  buttock 
on  that  side  will  be  almost  if  not  entirely  obliterated,  the 
great  protuberance  itself  being  flattened  out  as  compared 
with  the  opposite  buttock.  If  the  disease  run  its  course, 
all  these  alterations  become  more  marked,  and  the  limb  ac- 
tually grow  shorter,  from  disappearance  of  the  head  of  the 
bone,  and  finally  even  firm  union  will  take  place  between 
the  hip  and  thigh  bones.  Then  in  walking  the  thigh 
moves  with  the  hip,  the  body  is  bent,  and  one  cause  of 
spinal  curvature  is  established. 

"  Housemaid's  knee  "  is  a  swelling  produced  by  en- 
largement of  a  sac  containing  fluid  which  exists  beneath 
the  skin  in  front  of  the  knee-cap.  Its  enlargement  is 
brought  about  by  constant  kneeling  on  hard  surfaces 
without  any  protection  pad,  so  that  there  is  much  pres- 
sure upon  this  part.  Small  elastic  and  occasionally 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       4$ 

painful  swellings  sometimes  form  at  the  back  of  the  wrist 
from  enlargement  of  similar  sacs,  which  occur  here  in 
connection  with  the  cords  or  tendons  passing  over  the 
bones  from  the  muscles  which  mar  the  ringers. 


CHAPTER  IV. 

CHANGES    IN   ORGANS. 

WE  now  come  to  a  very  important  part  of  the  subject,  the 
organs  of  the  body,  and  the  influence  their  various  struc- 
tural changes  exert  upon  external  parts.  It  will  be  well  to 
pass  with  brevity  over  the  natural  disposition  of  the  viscera, 
so  that  we  may  the  more  readily  appreciate  these  facts. 

The  brain  which  is  contained  within  the  cavity  of  the 
skull  is  not  closely  applied  to  the  sides  of  the  cavity, 
but  is  invested  with  certain  membranes,  one  thin  and 
full  of  blood-vessels  closely  applied  over  the  whole  surface 
of  the  brain,  the  other  dense  and  tough,  lines  the  interior 
of  the  skull,  but  is  not  in  actual  contact  with  the  brain. 
For  the  smooth  outer  surface  of  the  one  membrane 
and  the  smooth  inner  surface  of  the  other  are  separated 
by  a  small  quantity  of  fluid,  and  although  here  and  there 
as  age  advances  the  virtual  cavity  winch  exists  between 
the  two  membranes  may  become  obliterated  by  the 
adhesion  of  the  membranes,  yet  there  is  seldom  complete 
blending  unless  from  disease. 


46      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

The  cavity  of  the  thorax,  which  extends  from  the  root 
of  the  neck  to  the  lower  end  of  the  breast-bone  in  front,  is 
separated  from  the  cavity  of  the  abdomen  by  the  midriff 
or  diaphragm,  an  expanded  muscular  structure,  which 
is  dome-shaped,  and  on  contracting  tends  to  descend  and 
thus  to  increase  the  capacity  of  the  thorax.  This  occurs 
every  time  the  lungs  are  filled  with  air  in  the  process 
of  respiration,  the  descent  of  the  diaphragm  being  one 
main  cause  of  the  enlargement  of  the  lungs  so  as  to 
allow  them  to  receive  more  air.  At  the  same  time  by 
virtue  of  the  muscular  structures  attached  to  them, 
the  ribs  are  raised  and  turned  outwards,  and  thus  the 
thorax  capacity  is  increased  in  a  lateral  direction.  The 
lungs  are  each  of  them  contained  in  a  thin  membrane  or 
pleura,  composed  of  two  layers,  the  outer  of  which  lines 
the  wall  of  the  cavity  of  the  chest,  and  the  inner  is  re- 
flected around  the  air-tubes  or  bronchi,  and  blood- 
vessels entering  the  lung  to  cover  the  whole  surface  of 
the  lung  itself.  Although  in  the  normal  state-  there  is 
no  actual  cavity  between  the  lung  and  the  chest-wall,  but 
only  the  virtual  space  between  the  smooth  surface  of  the 
costal  pleura  (as  it  is  called)  on  the  one  hand  and  the 
pulmonary  pleura  on  the  other,  it  is  usual  to  speak  of 
the  "  pleural  cavity  "  when  we  mean  that  half  of  the  chest 
cavity  which  contains  a  lung.  The  shape  of  this  is  roughly 
that  of  half  a  cone,  the  apex  being  upwards  behind  the 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.      47 

highest  rib  and  collar-bone,  the  base  being  on  the  surface 
of  the  diaphragm.  But  between  the  two  pleural  sacs,  and 
encroaching  chiefly  on  the  space  occupied  by  the  left, 
lies  the  heart,  contained  in  its  own  bag,  the  pericardium, 
and  the  large  blood-vessels  coming  off  from  the  heart. 

In  the  abdomen  are  contained  the  organs  of  digestion 
and  of  the  urinary  excretion,  as  well  as  an  organ  which 
probably  has  something  to  do  with  the  formation  of 
the  blood — the  spleen.  The  spleen  lies  behind  the 
last  ribs  on  the  left  side  in  close  contact  with  the 
diaphragm ;  on  the  right  side  behind  the  ribs,  and  in 
the  arch  of  the  diaphragm,  extending  also  beyond  the 
middle  line  to  the  left,  and  projecting  a  short  distance 
below  the  ribs,  is  the  liver.  Partially  concealed  by  its 
left  lobe  lies  the  stomach,  the  left  extremity  of  which  is  in 
contact  with  the  spleen.  Immediately  below  and  behind 
the  stomach  is  the  pancreas  or  sweetbread,  which  pours 
its  secretion  into  the  commencement  of  the  intestine  at  a 
spot  where  the  duct  of  the  liver  also  sends  the  secretion 
of  that  organ,  the  bile.  The  rest  of  the  abdominal  cavity 
is  occupied  by  the  coils  of  the  intestine,  and  the  kidneys, 
the  latter  lying  deeply  imbedded  in  each  flank.  Lastly, 
passing  down  from  the  thorax  through  the  cavity,  and  in 
close  contact  with  the  spine,  is  the  great  blood-vessel, 
the  aorta,  sending  off  branches  in  its  course  to  the  organs, 
arid  at  the  lower  lumbar  region  dividing  into  vessels 
4 


48      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

for  the  supply  of  the  pelvis  and  lower  limbs.  This  great 
arterial  trunk,  taking  blood  from  the  heart,  is  accompanied 
in  its  course  by  a  large  venous  trunk,  the  vena  cava, 
bringing  back  the  blood  from  the  lower  extremities  to  the 
heart.  Much  of.  the  blood  from  the  viscera  passes  by 
another  route  to  the  heart,  viz.,  through  the  liver. 

Confined  as  it  is  within  a  rigid  box,  it  is  not  likely  that 
the  brain  by  any  change  in  its  shape  can  in  the  adult 
exert  any  influence  on  the  shape  of  the  skull  and  there- 
fore of  the  external  configuration  of  the  head.  So  it 
happens  that  when  any  growth  or  tumour  occurs  in 
connexion  with  the  brain,  it  does  not  cause  the  skull  to 
change  its  shape,  but  rather  the  brain  itself,  which,  being 
of  less  resistance,  yields,  and  is  displaced  by  the  new 
growth.  It  is  different,  however,  in  infancy,  when,  as  we 
have  seen,  the  bones  of  the  skull  are  but  imperfectly 
developed,  when  their  ossification  is  far  from  complete, 
and  when,  soft  in  themselves,  they  are  separated  by  still 
softer  and  more  yielding  membrane.  At  this -period  of 
life  if  the  brain  enlarge  it  causes  enlargement  of  the 
skull,  and  the  condition  which  best  shows  that  is  that 
unfortunate  condition  popularly  termed  "water  on  the 
brain,"  or  technically  "  hydrocephalus."  In  this  state 
the  brain  is  actually  enlarged  by  the  secretion  of  a  large 
excess  of  fluid  in  the  spaces,  or  as  they  are  termed 
the  ventricles,  which  exist  within  the  nervous  substance. 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       49 

In  proportion  as  the  fluid  is  formed  the  capacity  of  these 
ventricles  increases,  and  the  whole  bulk  of  the  brain  is 
enlarged.  Then  also  the  cavity*  of  the  ^ 

skull  enlarges  and  the  head  assumes  a 
rounded  shape,  in  which  the  cranial  part 
is  out  of  all  proportion  to  the  small  facial 
part  in  a  painfully  grotesque  manner 
(Fig*  8).  A  comparison  of  this  form  of 
enlargement  of  the  head  with  that  pro- 
duced by  the  perverted  growth  of  the 
cranium  in  rickets  (Fig.  9)  shows  that  in  hydrocephalus 
the  skull  tends  to  the  globular  form,  whereas  in  rickets, 
the  square-shaped  protuberant  forehead  and 
the  projecting  occiput  are  surmounted  by 
almost  a  flattened  vertex.  Sometimes,  in 
consequence  of  this  hydrocephalus,  the 
cranium  attains  an  enormous  size.  Nor 
does  it  always,  although  very  frequently, 
terminate  in  early  death.  The  progress  may 
be  arrested,  but  the  enlargement  never  subsides,  and 
throughout  life  the  rounded  form  of  the  head  may  be 
retained.  Often  bones  not  present  in  the  normal  skull 
are  developed  to  fill  up  the  spaces  of  membrane. 

Here  we  may  turn  aside  for  a  moment  to  glance  at 

*  Outline  of  hydrocephalic  head. 

f  Outline  of  ricketty  head.     The  deformity  in  this  instance  is  not 
very  pronounced. 


50      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

the  position  assumed  by  the  phrenologist.  It  is  a  position 
wholly  untenable,  and  we  should  not  have  deemed  it 
worthy  of  refutation  here  were  it  not  that  misled  by  the 
recent  discoveries  of  physiologists  with  regard  to  certain 
facts  of  experiment  and  disease,  it  has  been  reiterated  that 
not  only  have  certain  regions  of  the  brain  their  special 
functions,  but  that  these  regions  are  indicated  on  the 
surface  of  the  skull  by  prominences  which  denote  similar 
development  of  the  brain  within.  Three  distinct  facts 
converge  to  utterly  explode  the  phrenologist's  standpoint. 
The  first  is  that  the  brain  is  not  in  actual  contact  with 
the  skull,  but  is  separated  from  it  by  a  membranous  sac 
between  the  inner  wall  of  which  and  the  surface  of  the 
brain  there  is  not  any  union.  The  second  is  that  the 
inner  surface  of  the  skull  does  not  correspond  at  all  in 
configuration  with  the  outer  surface,  for  on  the  vault  of 
the  skull  there  is  interposed  between  what  are  called  the 
inner  and  outer  tables  a  layer  of  loose  textured  bone  of 
variable  thickness,  and  in  the  frontal  region  there  is 
developed  to  a  very  variable  extent  in  different  individuals 
a  series  of  cavities  between  these  two  tables,  the  size  of 
which  amplifies  or  diminishes  the  amount  of  the  forehead. 
The  third  is  that  even  in  parts  where  these  cells  do  not 
exist,  the  thickness  of  the  skull  is  very  variable  in  different 
individuals,  and  prominences  occur  in  larger  number  and 
extent  in  some  than  in  others,  according  to  the  size  and  • 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       51 

strength  of  the  muscles  attached  to  them.  Thus  a  small 
skull  with  thin  walls  may  contain  a  comparatively  large 
brain,  and  vice  versd.  But  even  if  the  reverse  were  the 
fact,  mere  size  of  brain  goes  for  nothing  in  estimating  its 
capacity,  and  more  will  be  learnt  by  studying  the  complexity 
of  its  constituent  elements  than  any  amount  of  happy  guesses 
and  shrewd  surmises  arrived  at  from  a  study  of  the  external 
surface  of  the  skull,  especially  when  it  is  remembered  that 
all  the  inferior  parts  of  the  brain  are  concealed  and  have 
no  relation  to  the  outer  regions  of  the  skull. 

In  the  neck  an  irregular  enlargement  on  each  side 
results  from  enlargement  of  bodies  connected  with  the 
lymphatic  system,  and  called  lymphatic  glands,  which, 
forming  a  chain  on  each  side  of  the  neck,  as  well  as 
beneath  the  jaw,  may  inflame  and  lead  to  the  formation 
of  abscesses,  which,  after  bursting  and  discharging  their 
contents,  leave  behind  unsightly  puckered  scars  in  the 
skin.  The  tendency  to  the  spontaneous  enlargement  of 
these  structures,  and  their  ready  inflammation,  is  most 
marked  in  the  strumous  or  scrofulous  type  of  constitution. 
Sometimes  an  enlargement  of  these  neck-glands  is  shared 
in  by  similar  change  in  the  like  glands  in  other  parts  of 
the  body,  and  large  irregular  tumours  may  grow  up  and 
conceal  the  natural  shape  of  the  neck.  The  Derbyshire 
neck  is  the  result  of  the  enlargement  of  a  structure  the 
precise  office  of  which  is  unknown.  This  is  a  fleshy 


52       PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

organ  called  the  thyroid  body  situated  immediately  below 
the  prominence  in  part  of  the  neck,  known  by  the  name 
of  "  Adam's  apple,"  and  consisting  of  two  lobes  con- 
nected by  a  narrow  isthmus,  which  passes  across  the  air- 
passage,  the  lobes  lying  one  on  each  side  of  the  voice 
organ  or  larynx.  By  its  enlargement,  which  often  is 
excessive,  there  ensues  a  large  prominence  in  front  of  the 
neck,  this  is  the  wen  or  "  goitre,"  frequent  in  Derbyshire 
and  in  many  parts  of  Switzerland  and  France. 

The  size  of  the  chest,  as  we  have  said,  is  ever  changing. 
It  enlarges  as  the  lungs  expand,  and  contracts  as  they 
empty.  Its  form  and  dimensions  also  largely  depend 
upon  the  condition  of  these  organs.  If  they  remain  from 
birth  not  fully  inflated,  there  is  corresponding  smallness 
in  the  form  of  the  chest  itself.  If  on  the  other  hand 
they  are  of  large  size,  and  unusually  capacious,  the 
thorax  is  large,  broad,  and  deep.  The  change  in  shape 
which  the  chest  undergoes  during  respiration  is  as 
follows-,  with  inspiration  the  diaphragm  descends,  that 
is  to  say,  becomes  less  convex  towards  the  chest;  and 
the  lateral  walls  of  the  chest  are  enlarged  by  the 
ribs  being  raised  by  means  of  certain  muscles  passing 
between  them,  and  the  upper  ones  by-muscles  going  from 
the  spine  in  the  neck  to  the  upper  rib,  and  also  slightly 
everted,  this  latter  action  being  most  marked  in  the 
lower  ribs.  An  elevatory  movement  combined  with  one 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       53 

of  expansion  takes  place  every  time  we  take  a  breath, 
and  if  the  breathing  be  forced  and  hurried,  other  and 
more  powerful  muscles  which  have  attachments  to  ribs, 
act  on  these  bones  and  increase  the  area  of  their  move- 
ment. But  as  the  ribs  are  (the  six  upper  directly  and  the 
three  following  indirectly)  connected  with  the  sternum  or 
breast  bone,  this  bone  is,  at  the  same  time  as  the  ribs  are 
raised,  thrust  bodily  forward.  There  is  thus  an  enlarge- 
ment of  all  the  diameters  of  the  chest,  the  vertical,  the 
transverse,  and  the  antero-posterior ;  the  cavity  is  in- 
creased in  length,  in  width,  and  in  depth  from  before 
backwards.  When,  on  the  other  hand,  the  lungs  are 
completely  emptied  of  air,  that  is,  at  the  close  of  a  number 
of  forced  expirations,  the  chest  is  narrowed  in  all  those 
diameters,  and  its  circumference  is  proportionately  less. 
Contrasting  the  position  of  the  ribs  in  the  two  conditions, 
note  that  at  the  end  of  a  full  inspiration  they  have  a 
nearly  horizontal  direction,  whereas  at  the  close  of  a 
de^ep  expiration  they  are  sloped  downwards  and  forwards, 
and  are  therefore  more  Vertical.  So  that,  in  fact,  the 
chest  looks  longer  but  narrower  when  its  lungs  are  less 
exp^ided  than  when  they  are  fully  distended.  Now  it 
is  not  at  all  uncommon  to  meet  with  people  the  confor- 
mation of  whose  chest  approaches  what  may  be  called  the 
"  inspiratory  type,"  and  quite,  if  not  more  common  those 
in  which  it  is  rather  of  "  expiratory  type."  The  small, 


54      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

contracted,  long  and  narrow  chest  is  sadly  too  common. 
By  no  means  indicative  of  present  disease,  it  yet  shows  a 
lessened  lung  capacity  more  plainly  than  any  other 
surface  indication,  and  is  therefore  to  be  regarded  as  a 
warning  sign.  What  produces  this  expiratory  form  of 
chest  ?  It  may  be  assumed  to  be  due  to  no  single  condition, 
but  rather  the  grafting  of  faults  of  training,  faults  of  dress, 
superadded  to  those  primary  defects  over  which  the  pos- 
sessor has  no  control,  and  for  which  heredity  is  re- 
sponsible, and  the  artificial  existence  of  the  race  more 
responsible  still.  The  preventable  causes  ought  to  be 
removed,  and  all  should  be  done  that  is  possible  to 
remedy  or  lessen  the  unpreventable.  A  multitude  of 
errors  in  our  artificial,  over-cultured  modern  life,  ought  to 
be,  nay,  must  be,  cleared  away;  and  stricter  attention 
paid  to  the  laws  of  health  if  the  tendency  to  this  defect  is 
to  be  combatted  at  all.  That  it  ever  can  be  thoroughly 
and  completely  overcome,  would,  however,  seem  almost 
impossible,  seeing  that  so  many  of  the  essentials  of  civi- 
lisation depend  upon  the  sacrifice  of  health ;  and  number- 
less trades  and  occupations  of  themselves  favour  the  per- 
petuation of  the  defect.  Sedentary  occupations,  especially 
such  as  require  constant  bending  to  work ;  the  evil  pro- 
duced by  close  study  over  books  on  benches  which  afford 
no  support  for  the  back,  and  the  want  of  complete  and 
systematic  exercise  of  muscles  and  of  lungs,  tend  to  produce 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       55 

this  contraction  of  the  chest,  and  act  with  greatly  increased 
force  when  the  organism  is  young  and  pliant.  The  round 
shoulder  goes  along  with  the  narrow  chest,  and  unless 
preventive  measures  are  taken  in  early  life,  both  become 
attributes  of  the  individual  which  cannot  be  shaken  off. 

Narrow  chests  are  mainly  to  be  feared  as  indicating  a 
diminished  lung  capacity  and  breathing  space.  But  it  is 
wrong  to  think  that  they  are  characteristic  of,  or  predis- 
pose to  consumption,  for  if  anything,  the  wide  though 
flattened  chest  is  more  to  be  feared  than  the  long  and 
narrow.  This  terribly  fatal  form  of  lung  disease  often 
selects  for  its  victims  the  broad-chested,  even  robust 
looking ;  and  whilst  on  this  it  may  be  well  to  point  out 
one  very  striking  fallacy  in  connexion  with  the  shape  of 
the  chest  in  this  affection, — a  disease  which  cripples  the 
lungs,  and  proceeds  to  their  destruction.  As  a  portion 
of  lung  disappears  the  chest-wall  falls  in,  and  hollows 
appear  under  the  collar-bones.  Now  it  might  be  thought, 
and  it  often  is  thought,  that  when  this  is  extremely  marked, 
so  that  the  collar-bone  seems  to  stand  out  one  or  two 
inches  from  the  chest,  the  disease  is  advanced  and  the 
result  hopeless.  It  is  true  that  there  is  advanced  disease 
at  that  part  of  the  lung,  but  as  to  hopelessness,  it  is  quite 
the  reverse.  The  shrinking  of  the  chest  shows  that  the 
disease  is  on  the  road  to  recovery  at  that  spot,  and  is  a 
sign  rather  of  arrest  than  of  progress.  Consumption  is  not 


56      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 


wholly  incurable.  Indeed  in  many  of  its  forms  it  is  curable, 
when  measures  are  early  taken  to  arrest  its  advance,  and 
the  sign  of  its  arrest  is  this  falling  in  of  the  chest. 

There  is  another  disease  which  in  its  "  cure  "  leads  to 
considerable  deformity  of  the  chest-wall,  and  that  is  one 
form  of  a  not  uncommon  result  of  catching  cold — pleurisy. 
Here  the  smooth  lining  membrane  of  the  chest  and 
covering  of  the  lung  is  inflamed,  and  as  a  consequence 
often  fluid  is  poured  out  into  the  chest,  and  the  lung 
is  squeezed  up  more  or  less  against  the  spinal  column. 
If  this  last  a  long  time,  and  no  measures  be  taken  to  get 
rid  of  the  fluid  and  allow  the  lung  to  re-expand  and  fill 
FIG.  10.*  tne  cnest>  the  fluid  is  gradually  absorbed 
back  into  the  blood.  But  the  lung,  unable 
to  recover  itself,  remains  compressed, 
and  as  the  fluid  slowly  disappears  the 
chest-wall  sinks  in,  and  thus  consider- 
able deformity  is  brought  arTout.  The 
deformity  shows  itself  not  only  in  shrink- 
ing of  the  rib,  but  in  a  lowering  of  the 
shoulder  on  that  side,  and  a  curving  of 
the  spine  (Fig.  10)  to  the  opposite  side. 
Still,  grave  as  this  change  is,  it  is  slow  in  progress,  and 
although  the  main  work  of  two  lungs  has  now  to  be  un- 
dertaken by  one,  there  is  recovery. 

*  Contraction  of  right  side  of  chest  after  pleurisy. 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       57 

In  rickets,  the  ribs,  like  the  rest  of  the  skeleton,  being 
soft  and  yielding,  offer  less  resistance  to  the  pressure  of 
the  atmosphere  than  if  they  were  firmly  ossified,  and  are 
also  less  able  to  act  as  supports  to  the  muscles  bearing 
on  them.  The  lungs  being  imperfectly  filled  with  air,  the 
chest-wall  tends  to  sink  in,  and  a  wide  groove  is  pro- 
duced on  each  side  of  the  breast  bone  from  the  yielding 
of  the  soft  ribs,  except  at  the  lower  part,  where  the  liver, 
stomach,  and  spleen,  the  highest  organs  in  the  abdJmen 
which  underlie  the  diaphragm,  or  muscular  septum  be- 
tween the  chest  and  belly,  prevent  their  falling  in.  This 
depression,  when  marked  to  a  full  extent,  gives  the 
shape  of  chest  known  as  the  pigeon-breast,  the  sternum 
appearing  to  be  thrust  forward  like  the  prominent  and 
keeled  breast-bone  of  birds.  When  from  any  cause 
the  entrance  of  air  into  the  lungs  is  impeded,  as,  for 
instance,  in  consequence  of  some  obstruction  to  the 
air  passage  by  enlarged  tonsils,  the  tendency  to  the 
formation  of  the  pigeon-breast  is  greatly  increased. 

A  deep  and  broad  chest — the  chest  of  "inspiratory 
type  "  results  from  enlargement  of  the  lungs,  an  enlarge- 
ment which  may  be  due  to  disease,  in  which  as  a  result 
of  continued  attacks  of  bronchitis,  or>of  asthma,  or  con- 
tinued exercise  of  the  lungs 'forcing  air  through  narrowed 
apertures,  as  in  the  playing  of  wind  instruments,  or  in  hard 
manual  work,  where  efforts  are  constantly  made  to  fix  the 


58      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

chest  when  it  is  full  of  air  so  as  to  give  greater  support 
to  the  large  pectoral  muscles  going  to  the  arms — the  lung 
becomes  permanently  enlarged,  arid  the  ribs  maintain 
more  or  less  their  position  of  full  inspiration,  viz.: — the 
horizontal.  In  that  way  the  barrel-shaped  chest,  as  it  is 
termed,  is  brought  about — it  is  deep  from  before  back- 
wards— and  instead  of  having  its  external  diameter  longer 
than  its  antero-posterior,  both  diameters  may  be  equal,  so 
that  the  circumference  of  such  a  chest  is  round.  Hence, 
although  the  lungs  are  so  large,  breathing  is  more 
laboured  and  difficult,  for  the  ribs  are  raised  to  their  full 
extent  and  no  longer  move  in  breathing ;  and  the  neces- 
sary enlargement  of  the  capacity  of  the  thorax  has  to  be 
brought  about  mainly  by  the  movements  of  the  dia- 
phragm, and  the  forcible  raising  of  the  upper  ribs  by 
the  muscles  passing  to  them  from  the  neck. 

Although  the  most  frequent  cause  of  change  in  the 
form  of  the  chest  depends  on  the  condition  of  the  lungs, 
yet,  especially  in  childhood,  when  the  ribs  are  .soft  and 
yielding,  the  heart  if  greatly  enlarged  will  cause  a  con- 
siderable bulging  of  the  chest-wall  over  it. 

The  abdomen  having  only  soft  and  fleshy  walls  is  liable 
to  any  amount  of  variation  from  the  condition  of  the 
organs  contained  within  it,  and  as  some  of  these  organs — 
the  stomach  and  intestines — are  very  distensable,  and  vary 
in  capacity  and  in  amount  of  their  contents  several  times 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       59 

a  day,  so  does  the  shape  of  the  abdomen  alter.  On  this 
point  we  may  only  state  here,  that  food  which  is  liable  to 
much  fermentation,  which  is  not  readily  digested,  and 
causes  the  development  of  much  gas,  acts  chiefly  in 
causing  distension  of  these  organs.  Hence  it  is  that 
vegetable  feeders  have  large  bellies.  Continued  and 
often-repeated  temporary  causes  may  thus  lead  to  per- 
manent deformity. 

Any  of  the  solid  organs  in  the  abdominal  cavity  may 
from  various  causes  undergo  change  in  shape,  and  size, 
and  lead  to  departure  from  the  normal  form  of  the  ab- 
domen. This  may  be  from  an  enlargement  of  the  organ 
in  all  direcfions,  or  from  its  unequal  enlargement  from 
the  growth  of  tumours  in  it.  Swellings  in  the  lower  part 
of  the  abdomen  or  in  the  groin,  may  be  produced  by  "  rup- 
ture," in  which  a  portion  of  the  contents  of  the  abdomen 
is  protruded  through  the  abdominal  wall  where  it  is 
weakest.  Such  swellings  will  increase  under  efforts 
which  bring  the  abdominal  muscles  into  action,  as  for 
example,  when  the  breath  is  held  and  a  vigorous  attempt 
made  to  lift  a  heavy  body. 

But  there  is  one  condition  in  which  the  abdomen  is 
uniformly  enlarged  and  assumes  a  globular  form.  That 
is,  dropsy  of  the  abdominal  cavity,  where  fluid  derived 
from  the  blood  fills  and  expands  the  sac  in  which  the 
viscera  are  contained.  In  proportion  as  the  amount  of 


6o      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

fluid  is  great,  so  will  the  form  of  the  abdomen  tend  to 
become  more  spherical ;  for  when  it  is  slight  the  fluid  lies 
at  the  lowest  part,  and  the  contour  will  vary  with  the 
position  of  the  subject — the  intestines  floating  on  the 
surface  of  the  fluid.  But  when  this  reaches  the  maximum 
amount  it  tests  the  expansile  capability  of  the  abdominal 
walls  to  the  uttermost,  and  they  become  stretched  tightly 
and  the  abdomen  gains  a  spheroidal  shape. 


CHAPTER  V. 

ARTIFICIAL   ALTERATIONS    IN    SHAPE. 

IT  is  the  prerogative  of  civilised  man  to  be  the  slave 
of  custom  and  of  fashion.  Still  among  savage  races 
there  is  often  as  much  adhesion  to  absurd,  irrational, 
and  almost  .harmful  observances  as  among  the  so-called 
cultivated.  Setting  aside  such  deformations  as  have 
no  great  significance,  we  may  speak  of  two  barbaric 
customs  only,  and  then  turn  to  civilised  communities 
and  see  the  analogous  instances  of  ignorant  folly,  ten 
times  more  foolish  and  stupid  (because  there  they  have 
not  the  excuse  of  ignorance),  that  prevail  among  them. 
It  is  customary  among  many  American  races,  especially 
the  Peruvians,  to  subject  their  infants  to  a  process  of 
compression  of  the  skull,  which  is  carried  out  to  such 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.      6 1 

an  extent,  that  a  deformity  remains  throughout  life, 
and  the  frontal  region  instead  of  rising  boldly  up  above 
the  orbits  appears  as  if  cut  away,  and  as  if  a  long 
but  slightly  inclined  plane  were  left  rising  gradually  from 
the  orbit  to  the  middle  of  the  vertex  of  the  skull.  The 
resulting  shape  is  so  peculiar,  and  the  facial  angle  thus 
produced  so  small  and  brute-like  that  there  is  no  wonder 
that  it  should  at  one  time  have  been  regarded  as  typify- 
ing a  peculiar  race  of  man.  The  process,  however, 
has  been  now  frequently  observed  and  recorded  by  com- 
petent travellers,  and  it  has  been  shown  that  in  different 
tribes  various  kinds  of  compression  are  practised,  with 
the  result  of  procuring  curiously  unsymrnetrical  crania. 
The  accompanying  figure  (Fig.  n)  is  a  reduced  outline 
from  an  engraving  of  such  a  skull  pIG  x  r  * 

from  Titicaca  in  Peru,  in  Dr. 
Pochard's  l  Natural  History  of 
Man,'  and  the  author  quotes  the 
opinion  of  Dr.  Scouler  as  to  the 
manner  in  which  the  compression 
is  effected.  He  says,  "  The  pro- 
cess is  slow  and  gentle,  so  that  the  child  does  not  appear 
to  suffer  in  any  way  from  so  unnatural  a  process,  nor 
do  the  intellectual  qualities  of  the  individual  appear 
to  be  in  any  degree  affected  by  it ;  on  the  contrary,  a 
*  Compressed  cranium  of  a  native  of  Titicaca. 


62       PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

flat  head  is  esteemed  an  honour,  arid  distinguishes  the 
freeman  from  the  slave." 

The  Chinese  custom  of  cramping  the  feet  of  female 
children,  consists  in  so  binding  them  up  that  the  toes 
and  heel  are  almost  brought  into  contact,  and  the  sole 
of  the  foot  bent  upwards  in  a  high  arch.  The  result 
FIG  12  *  upon  the  shape  and  structure  of  the  foot 
and  of  the  leg  is  very  marked  (Fig.  12), 
the  bones  of  the  toes  and  foot  itself 
being  small  and  atrophied  and  com- 
pressed, whilst  the  muscles  in  the  leg 
which  should  act  on  the  toes,  but  which 
are  never  called  into  action,  are  wasted  and  small. 

Turning  to  the  " civilised"  customs;  the  high-heeled 
boot  of  modern  female  fashion  does  not  favour  the  de- 
velopment of  calf-muscles,  seeing  that  it  throws  the  foot 
forwards  on  the  toes,  and  normal  progression  cannot  take 
place.  The  wearing  of  small  and  tight  boots — a  far  more 
prevalent  evil — leads,  as  is  well  known,  to  much  dis- 
comfort in  progression  and  much  deformity  of  the  feet. 
The  toes  cramped,  distorted,  and  displaced,  become  the 
seat  of  thickenings  of  the  skin  where  pressure  is  most  felt, 
and  corns  and  bunions  come  to  disfigure  the  natural 
elegance  of  a  well-formed  foot.  One  other  evil  resulting 
from  the  wearing  of  improperly-made  boots  is  the  flat 
*  Foot  of  Chinese  woman  (after  Humphry). 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       63 

foot,  in  which  the  strong  fibrous  ligament  that  passes 
under  the  bones  of  the  foot  and  maintains  its  natural 
arch  is  weakened,  and  the  whole  structure  yields. 

The  wearing  of  tight  stays  and  corsets — the  folly  of 
which  is,  that  they  are  worn  with  the  avowed  object  of 
distorting  the  figure — leads  to  compression  of  the  lower 
part  of  the  chest,  interfering  with  its  movements  in 
breathing,  and  displacing  the  abdominal  organs.  Apart 
from  the  foolishness  of  the  practice  from  an  aesthetic 
point  of  view,  it  is  still  more  unwise  in  a  hygienic,  as 
there  can  be  no  doubt  that  compression  of  the  chest 
must  both  impair  the  action  of  the  breathing  muscles, 
and  render  the  muscles  compressed  by  it  weak  and  in- 
effective. But  in  spite  of  much  attack  the  practice  holds 
its  ground,  and  so  it  will  as  long  as  there  are  foolish 
women  enough  in  the  world  to  think  that  a  small  waist 
is  a  thing  of  beauty. 

Other  pieces  of  clothing  which  are  worn  habitually 
tighter  than  they  need  be,  such  as  stockings,  may  not  be 
productive  of  much  change  in  figure,  though  to  the  last- 
mentioned  articles  must  undoubtedly  be  attributed  many 
cramped  and  deformed  toes ;  that  tight  garters  should 
be  discarded  is  obvious,  since,  by  compressing  the  veins 
of  the  leg,  they  retard  the  flow  of  blood  from  the  limb, 
and  are  a  prime  cause  of  enlarged  veins  in  the  leg  and 
swelling  of  the  foot  and  limb. 
5 


64      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

The  barbaric  habit  of  wearing  earrings  might  almost  be 
considered  a  harmless  one,  for  it  does  not  much  alter 
the  shape  of  the  ear-lobe,  were  it  not  that  the  act  of  pierc- 
ing the  lobe  and  inserting  rings  is  apt  to  be  followed,  in 
young  children  especially,  by  troublesome  inflammation 
of  the  skin  at  the  part  pierced.  It  is  no  uncommon  thing 
to  find,  among  the  lower  classes,  mothers  nursing  infants 
a  few  months  old  who  are  already  in  the  possession  of  the 
coveted  ornament. 

But  it  is  time  to  turn  from  this  section  of  our  subject, 
so  leaving  the  question  of  deviations  of  form  (although 
much  more  might  be  said  of  them  did  space  permit),  we 
pass  to  those  of  changes  in  the  colour  of  the  body ;  and 
in  the  first  place  let  us  make  clear  upon  what  this  colour 
depends. 

CHAPTER  VI. 

.    THE    COLOUR    OF   THE    HUMAN    BODY. 

WHAT  is  the  cause  of  the  red  colour  of  the  blood?  It 
took  a  long  time  to  answer  this  question.  Men  had  to 
wait  until  the  microscope  was  first  applied  to  the  investi- 
gation of  the  blood  by  Malpighi,  about  two  hundred  years 
ago,  before  it  was  answered.  And  then  it  was  found  that 
this  blood— this  red  fluid  was  really,  so  far  as  its  fluid  part 
went,  colourless,  but  that  with  the  colourless  fluid  or  serum 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       65 

were  mingled  a  number  of  small  round  bodies  to  which 
the  name  corpuscles  were  given.  Then  it  came  to  be 
found  that  of  these  corpuscles  there  were  two  kinds,  some, 
and  these  formed  the  large  majority,  were  of  a  pale 
yellowish  red  colour,  hence  called  "  red  corpuscles ; " 
whilst  others,  larger,  less  regular  in  shape,  were  pale  or 
devoid  of  colour.  Ever  since  that  time  attention  has 
been  largely  directed  to  the  nature  and  properties  of 
these  constituents  of  the  blood,  and  we  must  describe 
them  in  slightly  more  ample  detail,  limiting  our  remarks 
only  to  the  red  corpuscles.  If  a  drop  of  blood  be 
placed  on  a  glass  slide  and  examined  under  the  micro- 
scope, the  field  will  be  seen  to  be  in  great  part  occupied 
by  small  circular  bodies,  in  which  a  faint  yellowish  tint 
indicates  their  possession  of  some  colouring  matter. 
They  are  not  only  circular,  but  are  flattened  from  side  to 
side,  and  careful  observation  will  show  that  their 
flattened  surface  is  really  depressed 
(Fig.  13).  They  are  in  fact  small 
discs  with  a  slight  concavity  on 
each  surface,  a  character  which  is 
perceived  at  once  when  a  corpuscle 
happens  to  roll  over  whilst  it  is 
being  observed,  and  the  observer 
sees  it  edgeways.  A  single  cor- 

*  Blood  corpuscles,  all  with  one  exception  being  red. 


66       PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

puscle  when  viewed  alone  seems  to  have  very  little  colour 
at  all,  a  mere  faint  tinge,  and  if  a  drop  of  water  be  added 
to  the  blood  the  corpuscle  will  swell  up  and  become  glo- 
bular, and  its  colour  will  become  even  fainter  than  before. 
But,  even  under  the  microscope,  it  will  be  seen  how  the 
corpuscles  are  sufficient  to  account  for  all  the  colour  the 
blood  possesses,  for  the  little  bodies  have  a  great  tendency 
to  collect  in  groups,  especially  forming  rows  like  a  pile  of 
coins,  and  then  the  colour  of  the  whole  group  is  more 
manifest.  If  further  proof  be  needed  that  the  colour  of 
the  blood  is  due  to  these  little  particles,  it  may  be  found 
by  collecting  a  small  quantity  of  blood  and  exposing  it 
to  the  air.  After  a  short  time  the  fluid  will  set — it  under- 
goes what  is  called  coagulation- — the  resulting  solid  mass 
being  called  a  clot.  This  clot  is  formed  by  the  pro- 
duction of  a  substance  from  the  fluid  part  of  the  blood 
known  as  fibrine,  which  does  not  exist  as  such  in  the 
blood  when  circulating  through  the  body.  The  fibrine 
is  formed  in  short  and  fine  threads  which  entangle  the 
corpuscles  in  their  meshes.  Now  the  red  corpuscles 
being  relatively  heavier  than  the  fluid  part  of  the  blood 
sink  to  the  bottom  of  the  vessel  during  the  process  of 
coagulation,  and  more  of  them  will  sink  the  slower  this 
process  takes  place.  Hence  it  comes  to  pass  that 
whereas  the  lower  part  of  a  clot  so  formed  is  of  a  dark  red 
colour,  the  upper  layers  may  be.  almost  colourless  ot 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       67 

only  just  tinged  by  reason  of  the  entanglement  of  a  few 
of  the  red  corpuscles,  which  have  not  had  time  to  sink  to 
the  bottom  of  .the  vessel  before  the  clot  set.  A  micro- 
scopical examination  of  a  portion  of  the  lower  part  of 
the  clot  will  show  that  there  the  fibrine  has  entangled 
nothing  but  red  corpuscles,  whilst  hardly  any  of  these 
corpuscles  will  be  found  in  the  upper  strata.  Again  it 
has  been  found  that  pale  blood,  or  the  blood  of  pale 
persons,  contains  fewer  red  corpuscles  than  the  average 
quantity  in  health,  and  even  quite  recently  it  has  been 
ascertained  that  the  red  corpuscles  themselves  may  contain 
less  colouring  matter  than  the  normal.  The  physiologist 
has  long  since  succeeded  in  separating  this  colouring 
matter  in  bulk,  and  obtaining  it  in  the  crystalline  state. 

The  chief  constituent  of  the  blood  pigment  or  hcemo- 
globin,  is  carbon,  which  forms  more  than  one-half  of  it ; 
oxygen,  nearly  a  quarter;  nitrogen  and  hydrogen  make 
up  all  but  a  small  fraction  of  the  remainder,  which 
yields  sulphur  and  iron.  The  most  important  property  it 
possesses  is  the  power  of  combining  with  oxygen,  and 
when  this  combination  occurs  the  colour  of  the  blood 
changes ;  it  becomes  brighter  and  more  scarlet.  If,  how- 
ever, the  oxidised  blood  be  exposed  to  carbonic  oxide  or 
carbonic  acid,  the  colour  changes  to  dark  purple.  This 
readiness  to  combine  with  oxygen  and  to  give  it  up  again 
appears  indeed  to  be  the  essential  property  of  the  red  cor- 


68      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

puscles,  and  the  difference  in  colour  thus  produced  con- 
stitutes the  essential  difference  between  the* blood  which 
flows/w;2  the  heart  in  the  arteries  to  all  parts  of  the  body, 
and  that  which  is  returned  to  the  heart  from  the  tissues  by 
the  veins.  When  ah  artery  is  divided  the  blood  that 
jets  forth  with  every  beat  of  the  heart  is  of  a  bright  red 
colour  •  on  the  other  hand,  that  which  flows  from  a 
divided  vein  in  a  constant  stream  is  dark  and  purple. 
The  reason  of  this  difference  in  colour  between  arterial 
and  venous  blood  arises  from  the  fact  that  before  entering 
the  left  side  of  the  heart  to  be  sent  through  the  body  by 
the  arteries,  the  blood  passes  through  the  lungs,  and  then 
the  carbonic  acid  with  which  the  venous  blood  is  charged 
is  at  once  exchanged  for  oxygen  by  the  process  of 
respiration.  Again,  the  bright  arterial  blood  carrying 
oxygen  to  the  tissues,  the  muscles,  glands,  &c.,  receives 
carbonic  acid  in  exchange  for  its  oxygen,  which  goes  to 
maintain  the  tissues  in  their  constant  process  of  change, 
and  the  dark  carbon-laded  blood  courses  .back  to  the 
heart  to  be  again  renewed  in  the  lungs.  If  from  any 
cause  this  process  of  oxygenation  of  the  blood  be  carried 
on  imperfectly,  or  if  the  heart  be  unable  to  do  its  work 
efficiently,  so  that  the  venous  blood  does  not  pass  on 
with  sufficient  rapidity,  then  the  blood  in  the  tissues  is 
less  bright,  and  as  will  be  seen  later  on,  the  surface  of  the 
body  denotes  the  darkening. 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       69 

Although  much  of  the  colour  of  the  body  depends 
upon  the  blood,  and  although  some  of  the  chief 
indications  of  derangement  of  health  may  be  found  in 
changes  of  the  colour  due  to  blood  conditions,  yet  there 
is  also  throughout  the  body  a  large  quantity  of  special 
pigment  deposited  in  different  regions.  This  colouring 
matter  wherever  it  occurs  is  brown  or  black,  and  is  met 
with  in  the  form  of  minute  particles  or  granules  within 
the  constituent  cells  which  make  up  the  various  structures 
where  it  is  found.  Derived  as  it  probably  is  from  the 
blood-colouring  matter,  its  composition  is  clearly  allied  to 
this  substance,  only  it  is  even  richer  in  carbon.  In  some 
places  where  it  is  deposited  it  subserves  definite  uses ; 
but  for  our  present  purpose  we  have  only  to  consider 
it  as  affecting  the  colour  of  the  body,  and  we  are  thus 
limited  to  its  consideration  in  influencing  the  colour  of 
the  skin,  of  the  hair,  and  of  the  eyes,  or,  more  strictly 
speaking,  of  the  "irides." 

Regarding  then,  for  our  present  purpose,  the  skin  only 
as  the  seat  of  colour,  and  leaving  for  others*  to  deal  with 
its  more  important  functions  as  an  excretory  organ  of  the 
body,  it  will  suffice  to  describe  the  structure  of  this 
integument  just  so  far  as  is  necessary  to  give  a  clear 
conception  of  the  cause  of  its  colouration. 

*  For  full  details  as  to  structure  of  skin,  see  work  in  this  series 
on  the  Skin. 


70      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

The  skin,  which  serves  as  the  protective  covering 
of  the  body,  is  a  tough  membranous  structure,  con- 
sisting of  three  parts,  an  external  layer  of  epidermis  or 
scarf-skin,  an  internal,  sensitive  and  vascular  layer  called 
cerium  or  true  skin,  and  an  intervening  soft,  spongy  layer 
called  the  rete  mucosum^  or,  after  its  discoverer,  rete 
Malpighii.  This  middle  layer  is  the  seat  of  collections 
of  fine  pigment  granules,  which  are  the  primary  cause  of 
diversity  of  colour.  In  dark  persons  this  layer  is  thicker, 
more  spongy,  and  contains  more  pigment  than  in  fair 
ones,  whilst  in  the  Ethiopians  it  is  very  thick  and  very 
black,  so  that  the  colour  of  the  blood  in  the  underlying 
corium  is  never  seen  at  all.  There  are  some  diseases, 
one  especially,  and  that  of  rare  occurrence,  which  are 
marked  by  a  gradually  increasing  deposit  of  this  pigment, 
so  that  a  previously  fair  skin  may  become  gradually  more 
and  more  bronzed,*  the  regions  which  are  naturally  the 
seat  of  most  pigment  being  those  which  suffer  most. 

A  "bruise"  is  the  name  given  to  the  effect . produced 
on  the  skin  by  an  injury  which  does  not  suffice  to  break 
the  skin  but  only  to  contuse  it.  The  blood  escaping 
from  such  blood-vessels  as  are  torn  in  the  injury  ^  collects 
under  the  skin,  and  the  gradual  variation  in  tint  that  a 

*  So  marked  is  this  that  the  affection  in  question  has  been  styled 
"  Bronzed-skin  Disease,"  although  the  coloration  of  the  skin  is  only 
a  part,  and  that  a  small  part,  of  a  deep-seated  disorder. 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       7 1 

bruise  undergoes,  from  purplish-red  to  green,  orange,  and 
yellow,  is  due  to  the  changes  taking  place  in  the  colouring 
matter  of  the  effused  blood,  whilst  this  is  being  very 
gradually  absorbed.  All  schoolboys  must  have  enjoyed 
opportunities  of  observing  these  colour-changes  in  the 
familiar  "  black  eye." 

Tattooing  consists  in  the  insertion  into  the  true  skin  of 
some  pigment  as  charcoal,  gunpowder,  &c.,  by  means  of 
punctures  made  in  the  skin  and  the  rubbing  in  of  the 
particles.  Once  inserted  there  the  pigment  remains,  and 
the  tattoo-mark  cannot  be  removed  by  any  means  short 
of  excision.  The  accompanying  sketch  (Fig.  14)  is  from 
a  microscopical  specimen  of  a  piece  of  skin  from  a 
highly-tattooed  arm.  Observe  that  the  pigment  is  not 
contained  in  the  epidermal  cells,  but  is  collected  in  little 
heaps  and  masses  between  the  bundles  of  tissue  that  form 
the  dense  cutis.  To  remove  them  by  simply  rubbing  the 
cuticle  off,  or  raising  a  blister,  will  not  suffice ;  and  as  a 
considerable  amount  of  tissue  would  have  to  be  taken 
away,  a  scar  must  ensue.  Hence  it  may  be  laid  down  as 
a  rule,  without  exception,  that  no  tattoo-mark  can  be 
removed  without  leaving  a  scar  to  indicate  the  place  it 
formerly  occupied. 

The  whiteness  of  scars  depends  on  the  fact  that  the 
middle  layer  of  the  skin  (or  at  any  rate  those  constituents 
of  it  which  contain  pigment),  is  not  reproduced  with  the 


72      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

healing  of  the  wound ;  and,  further,  the  new  tissue  formed 
in  the  corium  contains  fewer  blood-vessels  than  the  old 
tissue  which  it  replaces.  A  curious  but  interesting  fact 
in  connexion  with  scars  is  their  growth  with  the  body ; 
that  is  to  say,  if  a  wound  or  injury  sufficient  to  leave  a 
scar  be  inflicted  in  early  life,  the  scar  formed  will  retain 

FIG.  14.* 


*-< 


its  comparative  size  to  the  rest  of  the  body,  although  this 
may  have  become  three  or  four  times  as  large  as  at  the 
time  of  the  infliction  of  the  wound. 

The  nails  and  hairs  are  structures,  which,  in  truth,  are 

*  Microscopical  section  of  tattooed  skin  :  a  is  the  surface  layer  or 
epidermis,  in  the  deeper  layers  of  which  the  true  pigment  of  the 
skin  is  lodged  ;  b  is  the  cutis,  and  imbedded  in  its  texture  will  be 
seen  black  masses  of  the  tattoo-pigment. 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       73 

nothing  more  than  modifications  of  epidermis.  The 
former  consist  of  a  transparent,  horny  substance,  firmly 
imbedded  in  the  true  skin,  the  pink  colour  of  which  can 
be  seen  through  them.  Constantly  growing  by  additions 
at  their  posterior  ends  they  project  over  the  ends  of  the 
fingers  and  toes,  and  if  uncut  may  attain  extraordinary 
dimensions.  The  nails  are  never  coloured  by  the  natural 
pigment  of  the  skin.  They  are  narrow,  long,  sharply- 
curved  and  pointed  on  the  delicate  fingers  of  the  finely- 
formed,  clear-complexioned  inheritant  of  a  tendency  to 
consumption;  whilst  after  acute  illness  they  frequently 
show  ragged  transverse  lines  and  fissures  denoting  that 
nutrition  has  been  gravely  affected.  The  hairs  which 
exist  over  nearly  the  whole  of  the  body  and  attain  their 
greatest  development  on  the  scalp,  are  horny,  fibrous- 
looking  structures  which  spring  from  little  pits  or  follicles 
imbedded  in  the  true  skin.  The  colour  of  the  hair 
depends  upon  the  accumulation  of  fine  granules  of  pig- 
ment in  its  substance. 

In  the  accompanying  sketch  (Fig.  15)  will  be  seen  a 
minute  portion  of  three  varieties  of  hair  from  the  heads 
of  different  individuals.  One  (a)  is  a  portion  of  a  white 
hair  from  the  head  of  an  old  man ;,  the  fibrous  and  scaly 
character  is  well  seen.  It  is  absolutely  devoid  of  pigment 
in  any  part.  Then  comes  a  piece  of  a  light  yellow 
hair  (£),  and  the  main  difference  between  this  and  the 


74      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 


preceding  will  be  seen  in  the  presence  in  the  former  of 
dots  and  linear  streaks  of  pigment  which  had  an  amber 
colour,  although  of  course  they  appear  dark  in  the  engrav- 
ing. Lastly  we  have  a  black  hair  (*:),  and  this  will  be  seen 
studded  with  pigment  granules  in  all  parts.  We  learn 
from  this  then  that  the  colour  of  the  hair  depends  on  the 
presence  of  pigment  particles  more  or  less  widely  dissemi- 


nated throughout  its  substance,  whilst  a  purely  white  hair 
is  distinguished  by  the  negative  character  of  the  absence 
of  all  such  pigment.  That  men's  hairs  have  Been  known 
to  turn  "  white  in  a  single  night,"  through  sudden  fear,  or 
some  equally  powerful  emotion,  is  perfectly  true.  Several 
well-authenticated  instances  are  recorded.  Not  that  the 
pigment  actually  disappears  from  the  hair ;  it  is  probably 

*  Hairs  of  different  shades  of  colour. 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       75 

only  concealed  by  the  development  of  air  or  gas  which 
suddenly  takes  place  at  the  roots  of  the  hair  and  penetrates 
the  structure.  Nor  do  such  changed  hairs  always  remain 
invariably  white ;  as  they  grow,  the  pigment  may  still  be 
formed,  so  that  the  same  hair  may  become  half  white  and 
half  black. 

Before  leaving  the  subject  of  the  colouration  of  the  skin, 
one  word  must  be  said  as  to  the  colour  of  those  structures 
called  the  mucous  membranes.  Where  the  skin  is  said  to 
end — that  is,  at  the  orifices  of  the  body,  at  the  eyelids, 
at  the  ears,  nose,  mouth,  &c. — it  is  replaced  by  a  mem- 
brane which  in  its  minute  structure  differs  but  little  from 
the  skin  itself.  Like  the  skin  it  consists  of  several  layers, 
but  the  colour  of  these  mucous  membranes  is  red  or 
pinkish  red,  the  very  vascular  tissue  beneath  showing 
through  the  thin  membrane.  Hence  it  is  that  the  lips 
are  red,  and  the  same  "  vascularity  "  prevails  throughout 
all  the  canals  and  passages  into  which  these  orifices  open. 

Finally,  no  description  of  the  colour  of  the  body  would 
be  complete  without  reference  to  the  colour  of  the  eyes. 
Of  the  general  structure  of  the  eyeball  and  its  constituent 
parts  it  does  not  concern  us  to  speak  here.*  The 
anterior  part  of  the  organ  is  all  that/  is  visible  to  us.  We 
see.  between  the  eyelids,  a  central  convex,  glassy  struo 

*  For  more  ample  details  see  the  work  in  this  series  on  the  Eye. 


76      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

ture  set,  as  it  were,  in  front  of  a  white  or  bluish-white 
surface,  "  the  white  of  the  eye,"  but  little  of  which  is 
visible  between  the  lids  when  the  eye  is  directed  straight 
forwards.  This  white  part  is  well  furnished  with  small 
blood-vessels,  which  when  the  eye  is  rubbed  or  irritated 
by  particles  of  dust,  &c.,  become  visible  and  give  it  a 
reddened  or  "  blood-shot "  aspect.  The  round  aperture 
seen  behind  the  centre  of  the  glassy  structure  and  called 
the  pupil  appears  black  to  the  observer ;  it  is  bounded  by 
a  circular  membranous  or  rather  muscular  curtain  called 
the  iris,  and  the  pupil  can  increase  in  size  or  diminish 
by  reason  of  the  muscular  fibres  which  compose  the  chief 
thickness  of  the  iris ;  fibres  going  round  it,  being  for  the 
purpose  of  diminishing  the  size  of  the  pupil,  and  others 
radiating  on  all  sides,  for  the  purpose  of  increasing  its 
size.  It  is  this  membranous  curtain  that  is  coloured, 
and  gives  the  colour  to  the  eye,  that  colour  depending 
upon  collections  of  pigment  'granules  in  a  layer  of  cells 
which  covers  its  hinder  surface.  In  dark  brown  eyes 
this  pigment  is  very  abundant ;  in  "  blue  "  and  "  grey  " 
eyes  it  is  very  scanty.  There  is  also  a  large  amount  of 
pigment  in  the  cells  composing  the  middle  membrane  of 
the  globe  of  the  eye,  the  choroid  coat  as  it  is  called. 
The  choroid  is  really  an  extension  of  the  membrane 
forming  the  iris.  In  dark-haired  and  dark-complexioned 
people  this  choroidal  pigment  is  very  abundant,  in  fair 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       77 

people  it  is  less  abundant,  and  in  the  curious  type  of 
"albinoes"  there  is  no  pigment  at  all  in  the  choroid. 
As  this  choroidal  pigment  subserves  a  definite  use  in 
vision,  causing  the  absorption  of  extraneous  rays,  such 
people  are  unable  to  see  in  strong  direct  light,  and 
consequently  in  the  bright  light,  or  even  in  the  simple 
diffused  light  of  day,  they  are  obliged  to  keep  their  eyes 
half  closed  in  order  to  see  anything. 

The  glassy  cornea  sometimes  becomes  opaque,  or  the 
seat  of  opaque  white  patches  from  inflammation.  The 
glazing  of  the  eye  in  death  is  produced  by  the  shrinking 
of  this  same  structure.  Another  change  affecting  the 
cornea,  as  old  age  approaches,  is  the  formation  of  an 
opaque  white  line  around  the  margin  of  the  cornea,  and 
travelling  round  it,  so  that  it  does  not  at  first  make  a 
complete  circle ;  it  is  known  as  the  arcus  senilis.  It  is 
part  and  parcel  of  the  degeneration  of  tissues  which  is  the 
natural  accompaniment  of  age.  Another  old-age  condi- 
tion, which  sometimes  takes  place,  is  the  hardening  and 
opacity  of  the  crystalline  lens — known  as  cataract,  such 
opacity  being  visible  to  the  observer  through  the  pupil. 

Having  just  mentioned  the  case  of  "  albinoes  "  it'  may 
be  convenient  to  sum  up  their  characters  now  and  have 
done  with  them.  A  true  " albino"  is  one  whose  skin, 
hair  and  eyes  are  wholly  devoid  of  pigment  from  birth 
onwards.  The  skin  is  thin  and  fair,  the  delicate  flesh- 


78      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

tints  due  to  the  colour  of  the  blood  showing  through  the 
cuticle  are  very  manifest;  the  hair  is  a  pure  white,  on 
the  scalp,  the  eyebrows,  eyelashes,  &c. ;  the  pupil  looks 
red,  like  a  white  rabbit's  eye,  from  the  absence  of  any 
pigment  on  the  choroid  at  the  back  of  the  eyeball,  so 
that  the  colour  of  the  blood  in  that  vascular  membrane 
is  reflected  through  the  transparent  media  of  the  eye; 
and  the  iris  also  is  destitute  of  colour,  or  rather  its  colour 
is  pinkish  or  red  for  the  same  reason  as  the  choroid  is. 
This  condition  of  "albinism"  is  said  to  be  less  common 
among  the  white  races  than  among  the  black,  so  that  a 
*  white  negro  "  is  a  verity.  There  are  instances  also 
where  this  albinism  instead  of  being  general  is  partial, 
the  result  being  a  sort  of  piebald. 

Among  the  white  races,  the  Indo-  European  stock, 
there  are  two  well-marked  types  of  colouration  of  the 
body.  From  each  of  these  there  are  numerous  departures 
and  variations,  still  even  in  common  parlance  it  is  custo- 
mary to  speak  of  a  person  being  "fair"  or  "dark" 
according  as  he  falls  under  one  or  the  other  description. 
The  typical  fair-complexioned  blonde  has  ^a  delicate  soft 
skin,  through  which  the  emotional  disturbances  of  the 
circulation  are  readily  seen,  fine  yellow  flaxen  hair,  and 
irides  of  a  bluish  or  greyish  tint.  The  dark-complexioned 
or  brunette  has  a  coarser  skin,  with  more  pigment  in  it 
in  the  usual  seats  of  this  pigment — black  hair,  or  shades 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       79 

of  brown  verging  on  black,  and  irides  of  a  nut-brown 
colour. 

The  difference  in  coloration  of  the  skin  between  inha- 
bitants of  hot  climates  and  those  of  temperate  races,  is 
probably  due  to  an  exaggeration  of  the  conditions  which 
are  undergone  by  white-skinned  men  after  prolonged 
exposure  to  heat.  The  cause  of  the  colour  of  the  negro, 
rests  in  the  great  accumulation  of  pigment  in  the  deep 
layers  of  the  epidermis  ;  that  pigment  is  derived  from  the 
colouring  matter  of  the  blood,  and  the  reason  of  its 
excessive  production  perhaps  depends  upon  some  deeper 
seated  changes  in  blood  formation  about  which  we  can  only 
form  conjectures.  It  is  suggested  that  the  liver,  which  is 
the  organ  most  readily  influenced  by  changes  in  tempera- 
ture, and  which  secretes  a  product  largely  pigmented,  viz., 
the  bile,  may  have  its  function  so  modified  that  an  excess 
of  pigment  is,  as  it  were,  left  in  the  blood.  At  any  rate 
there  is  a  reason  for  the  coloration  of  dark  skins,  since 
they  serve  as  a  protection  from  the  effects  of  heat  to  the 
delicate  structures  beneath. 

The  "  tanning  "  of  the  skin  of  exposed  parts,  which 
occurs  after  a  few  days'  exposure  to  the  air  and  solar 
rays,  is  due  doubtless  in  part  to  increased  vascularity  and 
escape  of  pigment  from  the  blood,  just  as  any  irritant 
applied  to  the  skin  will  produce  pigmentation  from  the 
congestion  it  causes.  Other  and  deeper  influences  may 
6 


8o     .PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

be  at  work,  but  we  can  hardly  invoke  here  the  hypothesis 
that  derangement  of  hepatic  function,  gravely  as  this 
is  affected  by  heat,  has  anything  to  do  with  it,  seeing 
that  the  result  is  only  shown  upon  those  parts  of  the  skin 
which  are  exposed  to  the  air.  The  influence  of  light  in 
this  connexion  should  not  be  lost  sight  of;  for  those 
who  work  in  dark  places  are  pallid,  just  as  plants  kept  in 
the  dark  are  ;  and  though  we  may  not  be  able  to  explain 
the  modus  operandi,  yet  we  must  think  that  light  has 
some  effect.  Fair  skins  are  especially  liable  to  pigmenta- 
tion from  exposure  to  air  and  light,  as  is  seen  in  the 
production  of  "  freckles  "  or  "  sun-spots  "  on  the  face  and 
neck,  and  hands.  These  are  nothing  more  than  limited 
collections  of  pigment,  and  as  is  well  known  they  often 
disappear  when  youth  is  passed. 


CHAPTER  IX. 

CHANGES    IN   COLOUR   IN    HEALTH. 

HITHERTO  we  have  spoken  only  of  changes  in  colour  due 
to  alterations  in  the  amount  of  pigment  in  different 
regions  of  the  body.  Many  of  those  changes  are  of  but 
slight  importance,  for  depending  upon  local  influences 
they  have  no  direct  relation  to  the  general  health  of  the 
individual.  It  is  far  otherwise  with  the  colour  changes 
we  have  now  to  deal  with;  foj  although,  as  we  have 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       8 1 

before  pointed  out,  it  is  probable  that  all  pigment  owes 
its  primary  origin  to  the  colouring  matter  of  the  red 
blood  corpuscles,  yet  variations  in  degree  of  pigmenta- 
tion of  parts  are  not  necessarily  associated  with  any 
marked  change  in  the  blood  itself.  It  will  be  remem- 
bered also  that  the  colour  of  the  skin  depends  upon  two 
factors,  the  chief  being  that  of  the  blood  circulating 
in  the  deep  layers,  that  gives  the  "  flesh-tint "  which 
artists  aim  so  strenuously  to  reproduce  in  all  its  delicate 
and  varied  hues — a  colour  too,  the  intensity  and  delicacy 
of  which  must  largely  depend  on  thickness  of  cuticle  ; 
and  the  other  being  the  presence  of  pigment  in  the 
cuticle — a  very  varying  condition,  but  one  which  in- 
fluences largely  the  predominant  colour,  and  which,  if 
in  excess,  as  in  the  negro,  will  suffice  to  completely 
disguise  the  flesh-tint.  However,  even  in  the  negro  there 
are  still  regions  which  show  the  blood  colour,  e.g.,  the 
mucous  membranes ;  and  observation  of  the  colour  of  the 
lips,  of  the  nails,  or  of  the  conjunctiva  of  the  eye,  will 
reveal  more  accurately  than  any  change  that  may  be 
noticed  in  the  skin,  the  change  that  has  taken  place  in 
the  vascular  regions  beneath. 

The  difference  in  colour  produced  by  difference  in  the 
quantity  of  blood  in  a  part  may  be  shown  by  a  very  simple 
experiment.  If  one  hand  be  held  above  the  head  whilst 
the  other  is  allowed  to  hang  down  by  the  side  for  a  few 


82       PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

minutes,  and  then  the  two  hands  compared,  the  one  will 
look  pale  and  white,  the  other  flushed  and  red.  The  first 
is  white,  because  by  holding  it  up  the  return  of  blood  from 
it  by  the  veins  has  been  aided  by  the  action  of  gravity;  in 
the  other  it  has  been  retarded  for  the  same  reason.  Thus 
temporarily  there  has  been  produced  a  condition  of  com- 
parative bloodlessness  or  anczmia  in  the  one  hand,  and  a 
condition  of  plethora  or  congestion  (hypercemia)  in  the 
vessels  of  the  other.  The  experiment  may  be  varied  by 
pressing  out  the  blood  from  one  hand,  when  you  will  get  a 
white  spot  where  the  pressure  was  applied,  and  conversely, 
if  the  part  be  rubbed  violently,  it  becomes  red  and  warm. 
The  reason  of  the  pallor  in  the  first  instance  is  obvious 
enough,  the  pressure  squeezes  the  blood  out  of  the 
vessels  of  the  part.  The  reason  of  the  redness  in  the 
latter  example  is  not  so  obvious,  and  requires  a  little 
further  explanation.  All  the  blood-vessels,  the  arteries 
more  particularly,  have  muscular  walls,  which  can  contract 
when  the  nerves  which  go  to  them  are  irritated,  just  as 
the  muscles  of  the  arms  contract  if  the  nerves  going  to 
them  be  stimulated,  as  they  always  are  when  by  an  act 
of  the  will  the  brain  sends  its  message  down  them  to 
exert  a  particular  movement.  The  modus  operandi 
however  in  connection  with  the  blood-vessels  is  different 
from  that  of  the  muscles  of  the  arm,  or  any  of  those 
which  are  under  the  control  of  the  will ;  for  the  muscular 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.      83 

walls  of  the  arteries  are  not  under  voluntary  control. 
The  nerves  which  go  to  them  do  not  pass  directly  from 
the  brain  or  spinal  cord,  but  are  connected  with  a  part  of 
the  nervous  system,  which,  although  in  part  dependent  on 
the  cerebro-spinal,  is  distinct  enough,  both  in  its  arrange- 
ment and  structure,  as  well  as  in  its  functions.  This  is 
the  system  of  organic  nerves,  or,  as  it  is  also  called,  the 
sympathetic  system,  and  it  consists  essentially  in  collec- 
tions of  nervous  cells  called  ganglia,  connected  by 
bundles  of  nerve  fibres  down  each  side  of  the  spine, 
and  from  which  proceed  other  nerves  to  the  involuntary 
muscles  all  over  the  body ;  to  the  muscle  of  the  heart,  to 
those  of  the  intestines  and  stomach,  &c.,  the  movements 
of  all  of  which  are  not  under  voluntary  control,  but  are 
essential  to  the  performance  of  the  function  of  these  organs. 
The  nervous  system  is  then  in  its  central  parts  duplex  ; 
there  is  the  brain  and  spinal  cord  from  which  nerves 
of  voluntary  motion  and  sensation  arise,  and  there  is  the 
sympathetic  system  from  which  nerves  of  organic  life, 
of  involuntary  movement  arise.  Going  back  to  our  illus- 
tration, we  find  that  the  arteries  of  the  body  are  kept  in  a 
state  of  contraction  by  the  sympathetic  nerves.  It  has 
been  shown  that  when  the  sympathetic  nerve  in  the  neck 
of  a  rabbit  is  paralysed,  the  ear  on  that  side  becomes  red 
and  hot,  and  increases  in  size.  There  is  in  fact  an  in- 
creased flow  of  blood  to  it,  and  this  flow  is  due  to  greater 


84      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

enlargement  of  the  blood-vessels,  i.e.,  they  are  dilated. 
The  influence  of  the  sympathetic  nerve  has  been  taken 
off  their  contracting  walls,  and  just  as  a  limb  is  para- 
lysed when  its  nerves  are  injured,  the  coats  of  the  blood- 
vessels are  paralysed.  But  when  the  nerve  is  stimu- 
lated, the  vessels  contract,  and  the  previously  engorged 
ear  becomes  cold,  pale,  and  white,  less  blood  passing 
through  it.  And  now  we  come  to  another  fact  which 
must  be  accepted  before  we  can  explain  the  reason  why 
the  hand  gets  red  when  it  is  vigorously  rubbed.  It  is 
this :  although  the  cerebrospinal  nervous  system  has  no 
direct  influence  over  the  involuntary  muscles  supplied  by 
the  sympathetic  nerve,  it  has  an  indirect  influence.  It 
possesses  the  power  of  arresting,  or  diminishing,  or,  as 
it  is  called  in  scientific  phrase,  "  inhibiting  "  the  action  of 
the  sympathetic  nerves.  Now  the  act  of  rubbing  the  hand 
stimulates  the  fine  sensory  filaments  of  the  sensory  nerves 
in  the  skin ;  their  stimulation  exciting  them  to  increased 
function,  they  inhibit  the  action  of  the  sympathetic  nerves 
governing  the  blood-vessels  in  that  part ;  and  the  control 
of  the  sympathetic  being  temporarily  suspended,  the 
arteries  dilate,  and  becoming  capable  of  receiving  more 
blood  than  usual,  the  part  they  supply  becomes  tem- 
porarily red  and  hot.  The  same  explanation  holds  for 
the  effects  of  other  kinds  of  irritation  or  stimulation  of 
sensory  nerves,  e.g.,  the  red  blush  produced  Ity  the  ap- 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       85 

plication  of  a  mustard  poultice,  and  carried  further  still, 
the  first  effect  of  a  %  blister  is  to  cause  reddening  of  the 
skin,  and  later  as  the  blister  rises  exudation  of  fluid 
from  the  blood  in  the  dilated  vessels  of  the  cutis.  In 
speaking  of  pigmentation  of  the  skin  due  to  the  effect 
of  heat,  we  said  that  the  first  effect  was  an  increase  in 
the  flow  of  blood,  and  no  doubt  it  is  due  to  this  that 
there  comes  to  be  increased  formation  of  pigment.  For 
a  brown  stain  is  often  long  left  after  the  application  of 
mustard  or  a  blister,  or  after  the  skin  has  been  inflamed 
for  some  time. 

We  are  now  in  a  position  to  explain  the  phenomena 
of  blushing  and  of  pallor  of  the  surface  from  fright.  In 
blushing,  which  is  always  most  marked  in  thin-skinned, 
fair  people,  and  which  is  by  no  means  limited  to  the 
face,  but  may  extend  over  the  neck,  shoulders,  and 
chest,  the  arteries  are  temporarily  dilated.  The  sense  of 
shame  acts  through  the  medium  of  the  brain  in  an 
involuntary  manner,  and  there  is  a  temporary  arrest  of 
the  function  of  the  nerves  going  to  the  blood-vessels. 
The  blood  seems  to  "  rush "  to  the  cheeks,  and  the 
individual  feels  hot  and  uncomfortable,  whilst  to  the 
observer  the  rosy  flush  will  be  seen  mantling  the  cheeks, 
ears,  and  forehead,  and  reaching  to  the  roots  of  the  hair. 
The  heart  beats  quicker,  and  the  whole  circulation  is 
temporarily  excited.  Then  as  the  emotion  sinks,  the 


86      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

blood  tint  fades  away,  and  matters  return  to  their  previous 
state  of  quiescence. 

In  the  opposite  condition,  that  of  pallor,  which  is  as- 
sociated with  the  emotion  of  fear,  especially  sudden 
shock,  the  skin  becomes  pale,  the  lips  lose  their  bright- 
ness, and  often  a  sense  of  coldness  even  to  shivering  is 
felt.  Here  we  have  a  temporary  diminution  in  the  flow 
of  blood — the  brain  acting  upon  the  heart — and  the 
surface  being  less  supplied  with  blood.  A  similar 
effect  is  produced  in  fainting.  The  rationale  of  the 
fainting  state  is  a  temporary  failure  in  the  action  of  the 
heart,  and  the  brain  failing  to  receive  its  full  supply  of 
blood,  unconsciousness  supervenes.  The  bloodlessness 
of  the  surface  typifies  the  bloodlessness  of  the  brain. 
The  return  of  blood  to  all  these  parts,  and  the  resto- 
ration from  the  fainting  state  is  accompanied  by  a  sense 
of  heat  and  fulness. 

And  so  again  the  final  hue  of  death,  in  all  time  obvious 
and  striking — "pallida  mors" — is  due  to  the  final  beats 
of  the  heart,  and  dying  contractions  of  the  arteries  send- 
ing the  life-stream  slowly  on  its  way  to  stagnate  in  the 
veins.  The  emptiness  of  the  arteries  and  the  capillaries 
gives  a  pallor  to  the  surface,  which  the  laden  veins  do 
not  overcome. 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       87 

CHAPTER  VIII. 

CHANGES    IN    COLOUR    IN    DISEASE. 

PASSING  from  conditions  giving  rise  to  pallor,  which  are 
physiological,  and  therefore  not  departures  from  healthy 
action  at  all,  we  are  confronted  with  a  set  of  causes  of 
undue  paleness  of  the  surface  which  depend  on  more  or 
less  grave  alterations  in  the  constitution  of  the  blood. 
The  pallor  in  such  cases  is  general  and  more  or  less 
lasting.  It  may  be  due  to  a  general  diminution  in  the 
quantity  of  the  blood,  with  or  without  any  alteration  in 
its  quality.  Great  losses  of  blood  are  obvious  causes  of 
this  anaemia,  and  in  such  cases  it  comes  on  rapidly. 
Or  a  long  and  tedious  illness  gradually  interfering  with 
the  nutrition  of  the  body,  and  therefore  with  the  for- 
mation of  the  blood,  will  be  denoted  on  the  surface  by 
the  paleness  of  the  skin  dependent  on  the  diminished 
and  altered  condition  of  the  fluid  in  the  blood-vessels. 

More  common  than  all,  and  striking  enough  in  its 
effects,  is  the  pallor  produced  by  unhealthy  trades  and  oc- 
cupations ;  by  life  in  badly-ventilated,  ill-lighted,  and  over- 
heated rooms.  Then  just  as  the  plant  grows  pale  when 
kept  from  the  light,  so  the  man  or  woman  loses  the  tint 
of  health  and  presents  a  blanched  appearance.  This  is 
the  state  of  general  bloodlessness  or  anaemia  which  is  so 
prevalent  in  so  many  of  our  townsfolk  and  factory  hands. 
The  lips  lose  their  natural  redness  and  become  pale, 


88      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

as  do  the  gums  also,  and  the  other  visible  mucous  mem- 
branes. A  white  line  on  the  thin  part  of  the  gum,  where 
this  stretched  over  the  prominent  canine  teeth,  is  an 
indication  of  this  anaemia.  The  skin  is  white  and  no 
longer  has  the  flesh  tint  natural  to  it.  Many  troubles 
arise  out  of  this  condition  of  impoverished  blood ;  for, 
being  poor  in  corpuscles  and  deficient  in  colouring  matter, 
the  functions  which  these  subserve  are  impaired,  and 
shortness  of  breath  on  exertion,  caused  by  the  demand  of 
the  tissues  for  oxygen  being  greater  than  the  small  num- 
ber of  oxygen  carriers  can  supply,  disturbed  and  im- 
perfect digestion,  disorders  of  the  mental  faculties,  sen- 
sorial  derangements,  &c.,  all  follow  in  the  train. 

But  it  may  be  said  that  numbers  of  persons  are  naturally 
pale,  and  apparently  bloodless,  but  yet  enjoy  good  health, 
with  none  of  these  grave  discomforts.  That  is  true, 
but  it  is  only  true  because  their  pallor  is  not  the  pallor 
of  true  anaemia ;  it  may  be  dependent  upon  the  condition 
of  the  circulation  in  their  skin  ;  or  the  skin  may  be 
thicker  in  them  than  in  other  folk,  who,  with  no  more 
blood,  are  yet  red-faced  and  healthy-looking.  Then 
these  people  do  not  exhibit  the  unnatural  paleness  of  the 
lips  or  nails,  or  the  mucous  membrane  under  the  eyelids — 
the  only  places  where  in  dark-complexioned  thick-skinned 
people  the  objective  signs  of  anaemia  can  be  with  con- 
fidence ascertained. 


PERSONAL  APPEARANCES  IN   HEALTH  AND  DISEASE.       89 

As  to  this  state  of  anaemia,  all  its  causation  may  be 
summed  up  in  derangement  of  those  processes  which 
are  concerned  in  blood-making ;  of  these,  digestion  and 
oxygenation  are  the  chief;  and  of  the  causes,  con- 
sequently, ill  digestion  and  bad  oxygenation,  in  other 
words  improper  food  and  bad  air,  are  the  predominating 
circumstances  contributing  to  this  state.  Various  as 
are  the  diseases  of  which  anaemia  plays  a  part,  the  pro- 
duction of  the  anaemia  itself  always  comes  back  to  this. 

Apart  from  its  association  with'  any  grave  disease  this 
poorness  in  the  quality  of  the  blood  is  common  among 
young  women ;  especially  those  who,  accustomed  to  out- 
door life,  are  called  upon  to  work  from  morning  to 
night  within  the  house — and  often  in  them  the  pallor  of 
the  surface  is  not  merely  paleness,  but  a  greenish  tint  of 
skin  replaces  whiteness.  The  period  of  the  growth  of 
the  body  when  great  demands  are  made  upon  the  func- 
tions of  assimilation  and  nutrition  is  a  favouring  time 
for  the  occurrence  of  anaemia ;  and  the  debility  and  pale- 
ness of  young  people  who  "  grow  too  fast "  find  here  an 
explanation. 

Increase  in  the  quantity  of  blood  may  be  considered  here 
only  in  its  local  relations  from  overfilled  blood-vessels, 
or  what  is  called  congestion  of  parts.  It  is  seen  in  the 
cheeks  in  the  "hectic  flush"  of  fevers,  and  in  the  early  stage 
of  an  inflamed  part,  redness  being  one  of  the  classical 


90      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

signs  of  inflammation.  The  cause  of  the  red  rash  in  scarlet 
fever  is  congestion  of  the  vessels  of  the  skin,  and  its  ready 
paling  on  pressure  of  the  skin  shows  that  the  blood  can 
be  displaced  from  the  vessels  of  the  surface.  Permanent 
congestion,  leading  to  permanent  redness  of  parts,  are 
not  at  all  uncommon ;  and  the  enlarged  congested  vessels 
can  be  traced  on  many  a  weatherbeaten  face,  or  in  the 
bloated,  reddened  features  of  the  habitual  drinker.  Tem- 
porary flushing  of  the  cheeks — apart  from  blushing,  but 
doubtless  conveyed  through  the  medium  of  the  nervous 
system — is  seen  frequently  in  indigestion,  and  is  the  usual 
result  of  the  ingestion  of  stimulants,  as  alcohol ;  and  an 
aggravated  degree  of  this  produces  what  is  known  as 
"  nettle-rash." 

When  the  blood  cannot  be  perfectly  oxygenated  in 
the  lungs,  or  when  from  any  cause  the  return  of  blood 
to  the  heart  is  hindered,  then  the  surface  assumes  more 
or  less  of  a  bluish  or  livid  tint.  This  is  seen  best  in  the 
parts  which  are  most  vascular,  e.g.,  the  mucous  mem- 
branes, as  the  lips,  or  the  regions  most  remote  from  the 
centre  of  the  circulation,  as  the  tips  of  the  fingers,  or  toes, 
ears  or  nose.  Simple  exposure  to  cold  will  do  as  much, 
causing  temporary  stagnation  of  the  blood  in  these  remote 
regions  of  the  body.  Prolonged  chilling  of  the  surface  is 
always  followed  by  reaction ;  the  blood  flows  back  to  the 
part  with  increased  vigour,  and  redness  replaces  pallor, 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       91 

and  not  only  the  redness  of  mere  congestion  of  vessels, 
but  that  denoting  inflammation ;  and  the  tender,  swollen, 
reddened  "chilblain"  is  thus  related  to  the  graver  "frost- 
bite," where  the  effect  of  cold  is  seen  in  its  severest  form. 

Jaundice  is  due  to  the  pigment  of  the  bile  finding 
entrance  into  the  blood,  either  because  too  much  bile  is 
manufactured  by  the  liver  than  can  be  got  rid  of,  or  else, 
and  more  frequently,  because  the  escape  of  the  bile  into  the 
intestines  is  hindered.  This  colouring  matter  then  stains 
all  the  tissues  yellow,  and  the  skin  and  the  white  part  of 
the  eye  show  the  colour  most  plainly.  If  the  cause  cannot 
be  removed,  then  the  colour  changes  gradually  from  a 
deep  orange-yellow  to  a  more  or  less  greenish  or  olive- 
green  tint.  But  in  such  cases  the  cause  is  probably 
beyond  removal.  Young  infants  frequently,  in  the  first 
few  days  after  birth,  before  their  respiratory  and  cutaneous 
functions  are  fully  established,  pass  through  a  slight  attack 
of  jaundice.  This  seldom  has  any  grave  significance. 

Passing  to  other  forms  of  change  of  colour,  we  may 
note  the  curious,  muddy  or  tawny,  complexion  of  people 
who  have  suffered  from  ague  or  marsh  fevers,  a  com- 
plexion which  goes  with  them  through  life,  and  is  pro- 
bably dependent  on  the  change  whidi  the  spleen — an 
organ  intimately  connected  with  blood  formation — 
undergoes  in  such  diseases. 

Lastly,  certain  substances  when  taken  into  the  blood 


92       PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

will  stain  the  skin  and  tissues.  Of  these,  silver  is  the 
most  notable  example ;  and  people  who  have  taken  this 
metal  medicinally  for  a  long  period,  are  liable  to  have  the 
skin  of  their  face  changed  to  a  bluish  leaden  hue  from 
the  action  of  the  light  upon  the  silver.  And  one  of  the 
most  marked  effects  of  chronic  lead  poisoning  is  the 
appearance  of  a  line  of  bluish  discoloration  along  the 
thin  part  of  the  gums  where  these  border  on  the  teeth. 

Then  many  disorders  of  the  skin  which  give  rise  to 
irritation,  congestion,  or  inflammation,  leave  behind  them 
permanent  yellow  or  brownish  marks  of  discoloration. 
There  is  one  common  affection  which  is  accompanied  by 
a  yellowish  pigmentation.  It  is  due  to  the  presence  of  a 
fungus  on  the  skin,  and  occurs  on  the  body  favoured  by 
clothing  and  uncleanliness.  It  is  readily  removable. 


CHAPTER  IX. 

ON    <  TEMPERAMENT/    '  HABIT/   AND    i  TONE.' 

FROM  the  earliest  times  it  has  been  matte;*  of  faith  among 
writers  on  medicine  that  all  mankind  can  be  subdivided 
into  a  few  groups,  each  with  sharply-marked  charac- 
teristics, and  each  with  certain  tendencies  to  particular 
affections.  How  much  truth  underlies  this  doctrine  it  is 
needless  to  inquire.  Let  it  suffice  that  even  now  we 
recognise  the  types  of  constitution  which  so  long  ago 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       93 

were  first  pointed  out.  Like  all  generalizations,  however, 
these  types  or  temperaments  require  to  be  dealt  with 
liberally  in  drawing  conclusions ;  and  in  the  majority  of 
cases,  an  approximation  to  the  characters  can  alone  be 
found,  and  when  found  are  not  of  much  practical  value. 
They  are  four  in  number,  and  the  terms  denoting  them 
have  crept  into  current  use  as  descriptive  of  mental  as 
well  as  bodily  qualities,  viz.,  sanguine,  lymphatic  or 
phlegmatic,  bilious  or  melancholic,  and  nervous. 

The  sanguine  is  characterised  by  healthy  vigour,  ac- 
tivity of  body,  and  of  mind;  with  ruddy  cheek,  well 
developed  muscles  which  are  used  with  delight.  There 
is  a  great  deal  of  tone  about  the  tissues,  which  are  well 
braced  up,  and  the  bright  aspect  of  the  face  is  repre- 
sentative of  the  hearty  condition  of  the  mind,  and  the 
cheerfulness  with  which  life  is  regarded.  Reverses  do 
not  sadden,  nor  sorrow  damp  the  brightness  of  the  walk 
in  life.  This  and  more  might  be  said  of  this  happy, 
healthy  condition,  which  is  happy  because  healthy.  The 
lymphatic  person,  however,  is  less  carried  above  his  life- 
conditions.  He  is  pale,  and  generally  fair  in  feature ; 
slow,  and  rather  dull  in  mind.  The  bilious  is  typified  by 
dark  hair,  a  thick,  dull  skin,  a  sluggish  mind,  rather  easily- 
provoked  temper,  and  a  liability  to  disorders  of  digestion 
which  cloud  the  mind  as  well  as  affect  the  body.  The 
nervous  on  the  other  hand  is  easily  roused,  constantly 


94      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

occupied,  but  seldom  continuously — ever  seeking  fresh 
fields  to  work  in,  without  in  any  of  them  pursuing  his 
work  to  the  end.  Highly  intelligent,  often  precociously 
so  in  youth,  the  mind  is  not  well-balanced,  so  that  the 
individual  is  excitable  in  temperament,  and  both  unduly 
depressed  by  failure  or  unduly  exalted  by  success. 

Another  term,  also  handed  down  to  us  from  antiquity, 
and  far  too  widely  employed,  is  "  habit,"  or  its  correlative, 
"  constitution."  For  example,  we  talk  of  people  being  of 
a  "  gouty  constitution,"  or  a  "  rheumatic  habit,"  or  as 
being  of  a  "  strumous  type,"  or  u  consumptive  tendency," 
judging  in  these  and  many  other  instances  from  appear- 
ances, but  meaning  no  more  by  the  phrases  than  that  the 
individuals  in  question  are  disposed  to  such  and  such 
particular  class  of  disorders.  In  a  broad  and  general 
sense  no  doubt — as  in  the  above-quoted  instances — true 
conclusions  may  be  arrived  at  simply  from  such  observa- 
tion, for  the  affections  they  denote  are  generally  de- 
pendent upon  some  inherited  constitutional  defects,  and 
are  stamped  upon  the  individual.  But  too  rigid  re- 
liance upon  certain  prominent  characters  as  indicative 
of  such  tendencies  is  liable  to  lead  to  much  erroneous 
inference,  and  it  is  noteworthy  that  even  the  same 
"  habit "  may  be  presented  under  wholly  different  cha- 
racters. For  example,  the  "  gouty "  man  is  quite  as 
often  pale,  thin,  and  flabby-textured,  as  plethoric  and 


PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE.       95 

heavy  in  build ;  and  the  strumous  child  as  frequently  fair- 
haired,  oval-faced,  and  thin-skinned,  as  coarse-featured, 
and  thick-lipped.*  When,  again,  the  term  "  habit "  is 
applied  to  such  diseases  as  "  apoplexy,"  the  error  is  very 
great ;  for  it  is  notorious  that  the  prevalent  idea  that 
individuals  with  thick,  short  necks  and  sanguine  tempera- 
ment are  the  more  liable  to  apoplexy  is  wholly  unfounded 
in  fact,  that  disease  depending  on  causes  equally  at  work 
among  the  lean  and  long-necked  as  among  the  former. 
Far  better  to  erase  the  word  "  habit "  from  the  vocabulary 
than  run  the  risk  of  such  misapplications. 

We  have  more  than  once  spoken  of  loss  of  "  tone," 
and  vague  as  the  expression  is,  it  is  well  to  dwell  on  this 
as  indicating  perhaps  better  than  anything  else  the  state 
or  condition  which  of  all  others  is  to  be  found  on  the 
side  of  unhealthiness.  Everyone  knows  how  much  dis- 
comfort and  inconvenience  to  themselves  and  to  others 
is  experienced  by  those  who,  suffering  from  no  definite 
derangement  of  any  organ,  are  yet  in  a  state  of  ill  health 
during  the  greater  part  of  their  lives.  Unable  to  resist 
even  the  slightest  influences,  and  feeling  "  well "  only  at 
rare  intervals,  there  is  something  in  their  constitution 
which  baffles  definition.  Their  aspect  is  generally  more 
or  less  pallid;  for  they  take  but  little  exercise,  and 

*  It  is  usual  to  regard  the  strumous  state  as  comprising  these  two 
distinct  types. 

7 


96      PERSONAL  APPEARANCES  IN  HEALTH  AND  DISEASE. 

undergo  but  few  exertions,  so  that  the  circulation  is  slow, 
and  cold  extremities  with  consequent  want  of  sleep  are 
their  bane.  The  skin  is  flabby,  often  moist,  and  the 
dark  shadows  under  the  eyes  denote  that  the  relaxed 
condition  of  the  skin  is  sufficient  to  obscure  its  natural 
colour.  The  same  flabbiness  belongs  also  to  their 
muscles ;  all  exertion  is  painful  and  wearisome,  as  well 
as  irksome,  and  a  general  debility  and  languor  accom- 
panies them.  How  many  does  not  this  typify,  and  how 
often  is  it  largely  the  result  of  want  of  personal  effort,  and 
personal  hygiene?  Contrast  such  habits  of  body  with 
those  of  the  sturdy  and  vigorous,  and  it  will  be  seen  that 
in  one  the  tonicity  is  deficient,  in  the  other  marked. 
Well-regulated,  but  not  over-violent,  open-air  exercise, 
careful  diet,  frequent  cold  bathing,  and  above  all  some 
definite  pursuit  to  engage  the  mind,  will  do  more  to 
restore  the  balance  in  the  former  than  a  course  of  me- 
dicinal treatment  however  tonic  and  however  prolonged. 
Our  highly-artificial  lives  have  much  to  do'  with  the 
prevalent  valetudinarianism  of  the  present  day ;  and  the 
customs  of  society  which  run  counter  in  so  many  ways  to 
the  teachings  of  common  sense,  have  done  more  evil  in 

this  respect  than  can  well  be  estimated. 

c    p 
THE   END.  °'  ^ 


14  DAY  USE 

RETURN  TO  DESK  FROM  WHICH  BORROWED 


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on  the  date  to  which  renewed. 
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UNIVERSITY  OF  CAIylFORNIA  LIBRARY 


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